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BOOKS 


ALBERT  S.  MORROW,  M.  D. 


Diagnostic  and  Therapeutic  Technic 

Octavo  ot  830  pages,  with  860  line- 
drawings.  Cloth,  $5.00  net. 
The  New  {2d)  Edition 


Immediate  Care  of  the  Injured 

i2mo  of  35;  pages,  with  242  illus- 
trations. Cloth,  $2.50  net. 
The  Ne^u  {2d)  Edition 


DIAGNOSTIC 


AND 


THERAPEUTIC  TECHNIC 

A    Manual    of  Practical    Procedures 
Employed  in  Diagnosis  and  Treatment 


BY 

ALBERT   S.   MORROW.   A.  B.,  M.  D. 

CLINICAX  PROFESSOR  OF  SURGERY  IN  THE  NEW  YORK  POLY- 
CLINIC; ATTENDING  SURGEON  TO  THE  WORXHOUSE  HOSPITAL, 
AND     TO    THE    CENTRAL    AND    NEUROLOGICAL    HOSPITAL 


WITH  860  ILLUSTRATIONS.  MOSTLY  ORIGINAL 


SECOND  EDITION,   THOROUGHLY   REVISED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 
1916 


Copyright,  lyit,  by  W.  B.  Saunders  Company.     Reprinted  January, 
1912,   and  January,   1913       Revised,  entirely   reset,  re- 
printed, and  recopyrighted     January,     igi.s 
Reprinted  July,  1915 


Copyri;;ht,  1915,  by  W.  B.  Saunders  Compnny 
Reprinted  November.  IQ15 


CoViNJ       ^ 


PSrNTED    IN    AMEBIC* 

PRESS    OF 

W.     B.     SAUNDERS     COMPANY 

PHILADELPHIA 


To  the  memory  of  my  Father 

Prince  a.  Morrow,  m.  D., 

This  book  is  dedicated 


PREFACE  TO  THE  SECOND  EDITION 

In  the  short  time  that  has  elapsed  since  the  pubKcation  of  the 
first  edition  of  this  work  many  advances  have  been  made  in  diagnosis 
and  treatment  necessitating  in  the  preparation  of  the  present  edition 
a  very  careful  revision  of  the  old  manuscript  and  the  addition  of 
much  new  material.  Many  new  illustrations  have  been  added  and 
some  of  those  appearing  in  the  previous  edition  have  been  redrawn. 
These  additions  have  resulted  in  a  somewhat  larger  volume,  though 
the  plan  of  the  original  work  has  been  followed  without  change. 
Every  effort  has  been  made  to  bring  the  present  volume  up  to  date 
and  to  maintain  the  thoroughly  practical  character  of  the  original 
work,  and  it  is  earnestly  hoped  that  the  changes  and  additions  that 
appear  in  this  new  edition  will  add  materially  to  the  usefulness  of  the 
book. 

Finally,  the  writer  wishes  to  express  his  appreciation  of  the  very 
kind  reception  accorded  this  book  by  the  Profession,  without  which 
this  revision  would  have  been  impossible. 

A.S.M. 
New  York  City. 


vn 


PREFACE 


In  this  volume  the  writer  has  endeavored  to  bring  together  and 
arrange  in  a  manner  easily  accessible  for  reference  a  large  number  of 
procedures  employed  in  diagnosis  and  treatment.  The  book  has  been 
given  the  comprehensive  title  "Diagnostic  and  Therapeutic  Technic." 
The  scope  of  the  work,  however,  can  be  best  appreciated  by  consulting 
the  table  of  contents  on  page  xi. 

While  some  of  the  methods  herein  detailed  belong  essentially  to  the 
domain  of  the  specialist,  the  majority  are  the  e very-day  practical  proce- 
dures which  the  hospital  interne  or  the  general  practitioner  may  at  any 
time  be  called  upon  to  perform.  So  far  as  the  writer  is  aware  there  is  no 
single  book  to  which  one  may  turn  for  information  along  these  lines. 
Text-books  of  the  present  day,  treating  exhaustively  as  they  do  of  the 
larger  problems  of  medicine  and  surgery,  must  of  necessity,  if  they 
are  to  be  kept  within  reasonable  limits,  omit  or  else  describe  in  a  most 
condensed  manner  these  so-called  minor  procedures.  If  the  reader 
desires  fuller  and  more  detailed  information  it  not  infrequently  happens 
that  it  is  necessary  for  him  to  consult  a  number  of  works  before  he 
obtains  all  the  desired  information.  To  supply  such  a  want  is  the 
object  of  this  book. 

The  plan  of  the  work  comprises,  first,  a  description  of  certain 
general  diagnostic  and  therapeutic  methods  and,  second,  a  description 
of  those  measures  employed  in  the  diagnosis  and  treatment  of  diseases 
affecting  special  regions  and  organs  of  the  body.  Operative  methods 
have  been  omitted  as  far  as  possible,  only  those  having  been  considered 
which  are  required  in  emergencies  or  which  form  a  necessary  part  of 
some  of  the  measures  described.  Each  procedure  has  been  given  in 
detail,  leaving  nothing  to  the  reader's  imagination.  For  this  reason, 
and  that  each  section  might  be  complete  in  itself  without  referring  the 
reader  to  other  portions  of  the  text,  some  unavoidable  repetition  occurs. 

All  important  steps  have  been  illustrated  so  that  the  reader  may 
grasp  at  a  glance  the  technic  of  the  various  procedures,  no  expense 
having  been  spared  in  this  direction.  Nearly  all  the  illustrations  are 
line  drawuigs  made  by  Mr.  John  V.  Alteneder,  head  of  the  W.  B. 


X  PREFACE. 

Saunders'  art  department,  from  photographs  under  the  author's  super- 
Wsion.  The  excellence  and  high  character  of  his  work  has  done  much 
to  elucidate  the  text.  In  instances  where  illustrations  from  other 
sources  have  been  utilized  due  credit  has  been  given. 

I  desire  here  to  express  my  heartiest  thanks  to  my  father,  Dr. 
Prince  A.  Morrow,  and  to  Drs.  T.  J.  Abbott,  J.  M.  Lynch,  J.  H.  Potter, 
and  J.  F.  McCarthy  for  many  valuable  suggestions  and  criticisms,  and 
to  others  who  have  assisted  me  in  various  ways  in  the  preparation  of  the 
manuscript. 

My  thanks  are  also  due  the  Kny-Scheerer  Co.,  of  New  York,  for 
ha\ang  kindly  furnished  many  of  the  instruments  from  which  drawings 
have  been  made. 

A.  S.  M. 

New  York  City. 


CONTENTS 


CHAPTER  I 


Page 

The  Administration  of  General  Anesthetics i 

Preparations  of  the  patient  for  general  anesthesia 2 

Stages  of  anesthesia 6 

Ether  anesthesia 8 

Chloroform  anesthesia 17 

Nitrous  oxid  anesthesia 23 

Nitrous  oxid  and  oxygen  anesthesia 27 

Nitrous  oxid  and  ether  sequence 28 

Ethyl  chlorid  anesthesia 30 

Anesthetic  mixtures 33 

Intubation  anesthesia 34 

Intratracheal  insufflation  anesthesia •.    .  36 

Anesthesia  through  a  tracheal  opening 40 

Intravenous  general  anesthesia 41 

Rectal  anesthesia .  44 

Oil-ether  colonic  anesthesia 47 

Scopolamin-morphin  anesthesia   . 48 

Accidents  during  anesthesia  and  their  treatment 48 

After-effects  of  anesthetics 55 

After-treatment  of  cases  of  general  anesthesia 57 

CHAPTER  II 

Local  Anesthesia 59 

Advantages  and  disadvantages  of  local  anesthesia 60 

Methods  of  producing  local  anesthesia 63 

Drugs  employed  for  local  anesthesia 64 

Preparation  of  patient  for  local  anesthesia 67 

Conduction  of  an  operation  under  local  anesthesia 68 

Local  anesthesia  by  cold 69 

Surface  application  of  anesthetic  drugs ' 70 

Infiltration  anesthesia 71 

Endo-  and  perineural  infiltration 76 

Practical  application  of  infiltration,  endo-  and  perineural  methods  of  anes- 
thesia to  special  localities 78 

Operations  on  inflamed  tissues  under  local  anesthesia 92 

Bier's  venous  anesthesia 93 

Arterial  anesthesia 97 

Spinal  anesthesia 98 

Sacral  anesthesia 105 

CHAPTER  III 

Sphygmomanometry 109 

Normal  blood-pressure no 

xi 


XI 1  CONTENTS 

Page 

Instruments  for  estimating  blood-pressure iii 

Technic  of  estimating  blood-pressure 114 

Variations  of  blood-pressure  in  disease 116 

CHAPTER  IV 

Transfusion  of  Blood 119 

Indications  and  contraindications 120 

Hemolysis 121 

Selection  of  the  donor 121 

Artery  to  vein  transfusion 121 

Technic  by  Crile's  method 125 

Brewer's  method 127 

Hartwell's  method 128 

Levin's  method 128 

Elsberg's  method 129 

Technic  by  Carrel's  suture 129 

Vein  to  vein  transfusion 131 

Injections  of  Human  Blood  Serum 132 

CHAPTER  V 

Infusions  of  Physiological  Salt  Solution  135 

Indications 135 

Preparation  of  normal  salt  solution 136 

Artificial  sera  for  infusions 137 

Intravenous  infusion 138 

Intraarterial  infusion 144 

Hypodermoclysis 148 

Rectal  infusion 151 

CHAPTER  VI 

Acupuncture 152 

Venesection 153 

vScarification 158 

Subcutaneous  Drainage  for  Edema 160 

Cupping 162 

Leeching 166 

CHAPTER  VII 

Hypodermic  and  Intramuscular  Injection  of  Drugs 170 

ADMINISTRATIO>r   OF    SaLVARSAN    AND    NeOSALVARSAN 1 75 

Administration  of  Diphtheria  Antitoxin 183 

Vaccination 188 

CHAPTER  VIII 

The  Treatment  of  Neuralgia  by  Injections 194 

Trifacial  neuralgia 194 

Sciatica 200 


CONTENTS  XIU 

CHAPTER  IX 

Page 

Bier's  Hyperemic  Treatment 203 

Passive  hyperemia 203 

Effects  of  h3^peremia 204 

Indications 206 

General  principles  underlying  hyperemic  treatment 207 

Passive  hyperemia  by  means  of  constricting  bands. 209 

Passive  hyperemia  by  means  of  suction  cups 215 

Active  hyperemia 220 

The  Diagnosis  and  Treatment  of  Fistulous  Tracts  by  IMeans  of  Bismuth 

Paste 223 

CHAPTER  X 

Collection  and  Preservation  of  Pathological  ^Material 227 

Method  of  making  smear  preparations  for  microscopical  examination.     .  227 

Method  of  inoculating  culture  tubes 235 

Collection  of  discharges  and  secretions  for  bacteriological  examination    .  238 

Collection  of  blood  for  microscopical  examination 245 

Collection  of  blood  for  bacteriological  examination 250 

Collection  of  sputum 252 

CoUection  of  urine 252 

Collection  of  stomach  contents. 254 

CoUection  of  feces 254 

Removal  of  a  fragment  of  solid  tissue  for  examination 254 

CHAPTER  XI 

Exploratory  Punctures ^58 

Exploratori'  punctures  in  general 258 

Exploratory  puncture  of  the  pleura 259 

Exploratory  puncture  of  the  lung 264 

Exploratory  puncture  of  the  pericardium 265 

Exploratory  puncture  of  the  peritoneal  cavit}" 268 

Exploratory  puncture  of  the  liver 269 

Exploratory  puncture  of  the  spleen 271 

Exploratory  puncture  of  the  kidneys 273 

Exploratory  puncture  of  joints 274 

Spinal  puncture 277 

Spinal  puncture  as  a  means  of  administering  antitoxic  sera 283 

CHAPTER  XII 

AsPIR.\TIONS 285 

Aspiration  of  the  pleural  cavity 285 

Aspiration  of  the  pericardium 293 

Aspiration  of  the  abdomen  for  ascites 296 

Aspiration  of  the  tunica  vaginalis 300 

Aspiration  of  the  bladder 303 

CHAPTER  XIII 

The  Nose  and  Accessory*  Sinuses 304 

Anatomic  considerations. 304 


XIV  CONTENTS 

Page 

Diagnostic  methods 309 

Rhinoscopy 309 

Inspection  of  the  nasopharynx  l)y  means  of  Hays'  pharyngoscope    .    .    .317 

Palpation  by  the  probe 319 

Digital  palpation  of  the  nasopharynx 322 

Transillumination  of  the  accessory  sinuses 323 

Skiagraphy 325 

Therapeutic  measures 325 

Nasal  douching 325 

The  nasal  syringe 329 

The  nasal  spray 330 

Direct  application  of  remedies 332 

Insufflations 334 

Lavage  of  the  accessory  sinuses 336 

Passive  hyperemia  in  diseases  of  the  nose  and  accessory  sinuses   ....  343 

Tamponing  the  nose  for  the  control  of  hemorrhage 343 

CHAPTER  XIV 

The  Ear 348 

Anatomic  considerations 348 

Diagnostic  methods 352 

Direct  inspection 354 

Otoscopy 355 

Determination  of  the  mobility  of  the  drum  membrane 359 

Hearing  tests 360 

Inflation  of  the  middle  ear  for  diagnosis 363 

Therapeutic  measures 370 

The  ear  syringe 370 

Instillations 373 

Application  of  caustics 375 

Inflation  of  the  middle  ear  for  therapeutic  purposes 376 

Inflation  with  medicated  vapors 376 

Injection  of  solutions  into  the  Eustachian  tubes 377 

The  Eustachian  bougie 378 

Massage  of  the  drum  membrane 380 

Incision  of  the  drum  membrane 381 

CHAPTER  XV 

The  Larynx  and  Trachea 385 

Anatomic  considerations 385 

Diagnostic  methods 389 

Laryngoscopy  and  tracheoscopy 389 

Direct  laryngoscopy 396 

Autoscopy 399 

Direct  tracheo-bronchoscopy 400 

Palpation  by  the  probe 407 

Skiagraphy 408 

Therapeutic  measures 408 

The  laryngeal  spray 408 

Direct  application  of  remedies 409 

Insufflations 411 

Steam  inhalations 412 


CONTENTS  XV 

Page 

Dry  inhalations 4^5 

Intubation 4i5 

Tracheotomy 424 

CHAPTER  XVI 

The  Esophagus 435 

Anatomic  considerations 435 

Diagnostic  methods 43° 

Auscultation 437 

Percussion 437 

Palpation 437 

Examination  by  sounds  and  bougies 437 

Esophagoscopy 445 

Skiagraphy 449 

Therapeutic  measures 449 

Lavage  of  the  esophagus •    •   449 

Dilatation  of  esophageal  strictures  by  the  bougie 45 1 

Intubation  of  the  esophagus 45^ 

CHAPTER  XVII 

The  Stomach ■ ■  46i 

Anatomic  considerations 461 

Diagnostic  methods    .• 462 

Inspection 464 

Palpation ■ ■    •  466 

Percussion 469 

Auscultation    .   ■ 47^ 

Inflation  of  the  stomach 47 1 

Extraction  of  stomach  contents  for  examination 474 

Test  of  motor  function 482 

Test  of  absorption  power 483 

Gastrodiaphany 483 

Gastroscopy 485 

Skiagraphy 493 

Exploratory  laparotomy 493 

Therapeutic  measures 494 

Lavage  of  the  stomach 494 

The  stomach  douche 499 

Gavage 502 

Duodenal  feeding 505 

Massage 5^7 

Electrotherapy 509 

CHAPTER  XVIII 

The  Colon  and  Rectum 5^3 

Anatomic  considerations 5^3 

Diagnostic  methods 5^7 

I.  Abdominal  Examination 518 

Inspection 5^8 

Palpation 5^9 

Percussion ■ 520 


XVI  CONTENTS 

Page 

Auscultation 520 

Inflation  of  the  colon 521 

Skiagraphy 524 

II.  Internal  Examination 524 

Inspection 526 

Palpation  by  the  finger 527 

Manual  palpation 529 

Examination  by  the  speculum  or  proctoscope 530 

Examination  by  sounds  and  bougies 537 

Examination  by  the  bougie  a  boule 538 

Examination  by  the  probe 539 

Lavage  of  the  bowel 540 

Examination  of  the  feces 541 

Therapeutic  measures 541 

Enemata 541 

Enteroclysis 546 

Saline  rectal  infusion 554 

Continuous  proctoclysis 556 

Nutrient  enemata 560 

Injection  of  fluids  or  air  into  the  bowel  in  intussusception 563 

Dilatation  of  rectal  strictures  by  the  bougie 565 

Colonic  massage 568 

Auto-massage 570 

Application  of  electricity  to  the  rectum  and  colon 571 


CHAPTER  XIX 

The  Urethra  and  Prostate 574 

Anatomic  considerations 574 

Diagnostic  methods 578 

Glass  tests  for  locating  urethral  pus 579 

Injection  test  for  locating  urethral  pus 581 

Inspection 581 

Palpation 582 

Examination  by  sounds  and  bougies 585 

Examination  by  the  bougie  a  boule 594 

Urethrometry 596 

Estimation  of  the  urethral  length 597 

Urethroscopy  in  the  male 598 

Urethroscopj'^  in  the  female 605 

Therapeutic  measures *.    .    .  607 

Urethral  injections 607 

Irrigations  of  the  urethra 611 

Instillations 616 

Application  of  ointments 618 

Urethroscopic  treatment 620 

Direct  application  of  cold  to  the  urethra 622 

Prostatic  massage 624 

Meatotomy 626 

Treatment  of  strictures  by  gradual  dilatation 627 

Treatment  of  strictures  by  continuous  dilatation 640 


CONTENTS  XVll 

CHAPTER  XX 

Page 

The  Bladder 642 

Anatomic  considerations 642 

Diagnostic  methods 644 

Urinalysis 646 

Inspection 650 

Percussion 651 

Palpation 651 

Sounding  for  stone 653 

Test  of  bladder  capacity 657 

Estimation  of  residual  urine 658 

Test  for  absorption  from  the  bladder 659 

Cystoscopy  in  the  male 659 

Cystoscopy  in  the  female ; 665 

Skiagraphy 671 

Therapeutic  measures 671 

Irrigations 671 

Auto-irrigations 675 

Instillations 676 

Cystoscopic  treatment 677 

The  destruction  of  vesical  growths  by  the  high  frequency  current    .    .    .  678 

Catheterization  in  the  male 680 

Catheterization  in  the  female 687 

Continuous  catheterization 689 

Aspiration  of  the  bladder 692 

CHAPTER  XXI 

The  Kidneys  and  Ureters 695 

Anatomic  considerations 695 

Diagnostic  methods 698 

Inspection 698 

Palpation  of  the  kidney 699 

Palpation  of  the  ureters 701 

Percussion 703 

Urinalysis 704 

Catheterization  of  the  ureters  in  the  male 705 

Catheterization  of  the  ureters  in  the  female 714 

Pyelometry 720 

Segregation  of  urine •  .  721 

Determination  of  the  functional  capacity  of  the  kidneys 725 

Skiagraphy 730 

Pyelography 731 

Exploratory  incision 731 

Therapeutic  measures 732 

Medication  of  the  renal  pelvis  and  ureters 732 

Dilatation  of  ureteral  strictures 733 

CHAPTER  XXII 

The  Female  Generatwe  Organs 735 

Anatomic  considerations 735 

Diagnostic  methods 737 


XVIU  CONTENTS 

Page 
I.  Examination  of  the  abdomen. 

Inspection , 742 

Palpation 743 

Percussion • 745 

Auscultation 747 

Mensuration 747 

II.  Examination  of  the  pelvic  organs. 

Inspection 748 

Examination  of  discharges 749 

Digital  palpation 750 

Bimanual  palpation 752 

Examination  by  means  of  specula 759 

Sounding  the  uterus 764 

Digital  palpation  of  the  uterine  cavity 766 

Examination  of  sections  and  scrapings  from  the  uterus 768 

Exploratory  vaginal  incision 768 

Therapeutic  measures 771 

Vaginal  irrigations 77 1 

Local  applications  to  the  vagina  and  cervix 774 

Application  of  powders  to  the  vagina 775 

Vaginal  tampons 776 

Intrauterine  douche 779 

Intrauterine  applications 783 

Tamponing  the  uterus 786 

Bier's  hyperemic  treatment  in  gynecology 789 

Pelvic  massage 789 

Scarification  of  the  cervix 791 

Pessary  therapy 792 

Dilatation  of  the  cervix 803 

Curettage 807 


Index 81 


o 


Diagnostic  and  Therapeutic 
Technic 


CHAPTER  I 
THE  ADMINISTRATION  OF  GENERAL  ANESTHETICS 

The  term  anesthesia  denotes  a  condition  of  insensibility  to  pain 
and  an  anesthetic  is  any  agent  which  produces  such  a  condition. 
Anesthetics  are  divided  into  general  and  local.  The  drugs  most 
used  for  general  anesthesia  are  ether,  chloroform,  nitrous  oxid  gas, 
and  ethyl  chlorid  administered  separately,  in  sequence,  or  in  combina- 
tion with  one  another. 

The  choice  of  the  anesthetic  agent  and  the  decision  as  to  the 
method  of  its  administration  are  questions  of  vital  importance. 
Under  any  general  anesthetic  the  patient  is  brought  practically  to  the 
border-line  between  life  and  death,  and,  in  many  cases,  the  life  of  the 
patient  depends,  in  the  first  place,  upon  the  selection  of  the  anesthetic, 
and,  in  the  second  place,  upon  the  way  in  which  it  is  administered. 
While  the  safety  of  the  patient  should  always  be  the  first  consideration 
and  the  main  guide  in  the  choice  of  the  anesthetic,  it  is  unfortunately 
impossible  to  lay  down  any  hard  and  fast  rules.  Each  case  must  be 
studied  separately,  and  the  anesthetic  chosen  that  is  best  suited  to 
that  particular  case.  The  production  of  narcosis  with  the  same 
anesthetic  under  all  conditions,  even  though  the  particular  agent 
chosen  were  statistically  safe,  would  certainly  be  unjustifiable.  An 
anesthetic  that  could  be  used  with  safety  under  some  conditions  would 
be  a  menace  to  life  under  others.  The  condition  of  the  patient,  the 
nature  of  the  operation,  the  anesthetist,  and  the  operator  himself  are 
all  factors  that  enter  into  consideration.  Furthermore,  in  estimating 
the  relative  safety  of  the  different  anesthetics,  one  must  consider  not 
only  the  immediate  dangers,  but  also  the  more  remote  toxic  effects 
that  frequently  do  not  appear  until  some  time  later.  No  general 
rules  will  be  laid  down  at  this  time  as  to  the  selection  of  the  anes- 
thetic, but  in  considering  each  agent  an  attempt  will  be  made  to 
indicate  the  cases  for  which  it  is  best  suited. 


2  TH£   ADMINISTRATION    OF    GENERAL   ANESTHETICS 

Preparations  for  Anesthesia  and  Precautions. — A  certain  amount 
of  preparation  of  the  patient  is  necessary  before  the  administration  of 
a  general  anesthetic.  Experience  teaches  that  the  patient  takes  an 
anesthetic  better  if  he  be  placed  upon  a  light  but  nutritious  diet  for 
several  days  before  operation,  and  the  bowels  be  properly  regulated. 
In  some  special  cases  it  ma}'  be  necessary  to  subject  the  patient  to  a 
very  careful  regime,  beginning  even  some  weeks  before  operation  in 
order  to  put  him  in  the  best  possible  condition.  In  other  cases  where 
only  a  light  anesthesia — as  from  nitrous  oxid — is  required,  but  little 
preparation  will  be  necessary. 

Care  of  the  Bowels. — When  possible,  the  intestinal  canal  should 
be  emptied  a  number  of  hours  before  anesthetization.  The  usual 
custom  is  to  give  a  purge,  consisting  of  castor  oil,  calomel,  compound 
licorice  powder,  or  magnesium  sulphate,  the  night  before  the  opera- 
tion, followed  by  a  soapsuds  enema  in  the  morning.  Often,  however, 
the  nature  of  the  operation  or  lack  of  time  does  not  permit  of  the 
administration  of  cathartics.  In  such  cases,  a  purgative  enema  is 
relied  upon. 

Diet. — The  diet  for  twenty-four  hours  before  the  operation  should 
be  of  an  easily  digestible  character,  and  should  be  taken  in  small 
amounts  to  prevent  overloading  the  alimentary  canal.  If  the  opera- 
tion is  set  for  earh-  in  the  morning,  no  food  should  be  given  after  a 
light  supper  the  previous  night;  if  it  is  fixed  for  the  afternoon,  a  very 
light  breakfast  may  be  taken,  not  later  than  8  a.m.  A  feeling  of 
faintness  or  weakness  may  necessitate  the  giving  of  a  cup  of  hot 
broth  or  beef  tea  even  later  than  this  in  some  cases,  but  it  should  be  a 
general  rule  not  to  give  any  food  by  mouth  within  three  hours  of 
the  time  for  anesthesia,  since,  if  the  stomach  is  not  empty  at  the  time 
of  operation,  vomiting  is  almost  sure  to  occur,  adding  not  only  to  the 
dajiger  of  the  anesthetic,  but  to  the  subsequent  distress  of  the  patient. 
In  some  cases  of  special  gravity  on  account  of  shock  or  marked 
feebleness,  a  nutrient  enema  (see  page  58),  with  the  addition  of 
whisky  or  brandy,  may  be  given  half  an  hour  before  the  anesthesia 
is  commenced. 

In  an  emergency,  lavage  of  the  stomach  may  be  performed  when 
a  full  meal  has  been  taken  shortly  before.  Preliminary  washing  out 
of  the  stomach  will  be  required  when  that  organ  is  the  seat  of  opera- 
tion; it  should  also  be  practised  if  a  general  anesthetic  is  to  be  admin- 
istered when  intestinal  obstruction  with  vomiting  is  present,  for,  in 
such  cases,  patients  have  been  known  to  fairly  drown  from  the  con- 
tents of  the  stomach  suddenly  pouring  out  under  the  relaxation  of  the 


PREPARATIONS  FOR  ANESTHESIA  AND  PRECAUTIONS        3 

anesthetic.  To  avoid  undue  excitement  and  possible  collapse,  the 
lavage  may  be  performed  just  as  the  patient  is  under  complete 
anesthesia. 

Preparation  of  the  Mouth,  Teeth,  Etc. — Preparation  of  the  nose, 
mouth,  and  teeth  lessens  the  dangers  of  aspiration  pneumonia  and 
septic  bronchitis.  As  a  rule,  cleansing  the  nose  and  mouth  with  an 
antiseptic  solution  and  thoroughly  brushing  the  teeth  is  sufficient, 
but,  in  some  instances,  the  neglect  of  the  teeth  results  in  a  very  foul 
and  septic  condition,  necessitating  systematic  treatment  for  several 
days  before  the  anesthetic  can  safely  be  administered. 

The  Preliminary  Use  of  Drugs. — A  good  night's  rest  does  much  to 
fortify  the  patient  and  put  him  in  the  best  possible  condition  for  the 
operation.  With  some  patients  simply  a  rub-down  with  alcohol  at 
bedtime  sufiices  to  induce  sleep;  for  others,  especially  if  nervous,  the 
administration  of  trional  or  the  bromids  is  indicated. 

Many  surgeons  administer  morphin  hypodermically  before  anes- 
thesia. In  some  cases  this  is  of  advantage,  shortening  the  stage  of 
excitement  and  necessitating  less  of  the  anesthetic  to  maintain  insen- 
sibility, but  it  should  not  be  a  routine  practice.  In  highly  excitable, 
vigorous,  alcoholic  individuals  it  is  of  distinct  advantage.  With  its 
use,  however,  it  is  necessary  to  maintain  lighter  anesthesia  than 
without  it.  The  chief  objection  to  morphin  is  that  it  depresses 
respiration  and,  by  its  action  upon  the  pupils,  may  mask  symptoms  of 
overnarcosis;  furthermore,  it  delays  the  awakening  from  the  anes- 
thesia. In  children  or  the  very  old  it  must  be  used  with  caution. 
Any  condition  producing  embarrassed  or  obstructed  respiration  is 
a  contraindication  as  is,  of  course,  any  idiosyncrasy  against  the  drug. 
It  should  not  be  given  to  very  weak  subjects  or  to  those  in  stupor. 

By  some  operators  atropin  gr.  i/ioo  (0.00065  gm.)  is  given  half 
an  hour  before  the  anesthetic  is  started  as  a  routine  procedure  for 
the  purpose  of  suppressing  the  secretion  in  the  upper  air  passages 
and  bronchi,  thus  lessening  irritation  of  the  respiratory  mucous 
membrane. 

Physical  Examination. — A  thorough  physical  examination  should 
be  made  in  all  cases  as  a  routine  preHminary  to  general  anesthesia,  for 
exact  knowledge  as  to  the  state  of  health  is  essential  to  an  intelligent 
selection  of  the  anesthetic  and  its  safe  administration.  Such  an 
examination  has  a  good  moral  effect  upon  the  patient,  and,  if  assur- 
ance can  be  given  that  nothing  abnormal  can  be  discovered,  it  does 
much  to  allay  the  natural  fear  and  timidity  of  a  nervous  individual. 
This  examination  should  include  a  record  of  the  pulse,  temperature. 


4  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

and  respirations,  a  physical  examination  of  the  heart,  arteries,  and 
lungs,  and  a  blood  and  urine  examination,  and  should  be  made,  when 
possible,  before  the  day  of  operation,  so  that  if  the  results  of  the 
examination  demand  it,  the  operation  may  be  postponed  without 
subjecting  the  patient  to  unnecessary  preparations.  In  the  presence 
of  acute  bronchitis  or  coryza,  a  postponement  of  the  anesthesia  is 
advisable.  Chronic  bronchitis,  however,  is  sometimes  improved  by 
an  anesthetic.  Heart  disease,  with  good  compensation,  is  not  a 
contraindication  to  general  anesthesia. 

The  urine  should  always  be  examined  if  the  case  is  such  that  time 
allows,  noting  the  total  amount  for  twenty-four  hours,  the  specific 
gravity,  and  the  amount  of  urea,  and  making  tests  for  albumin,  sugar, 
etc.,  as  well  as  a  microscopical  examination  for  casts.  The  quantity 
of  urea  eliminated  within  twenty-four  hours  is  especially  important. 
A  normal  adult  male  will  pass  250  to  450  gr.  (16  to  29  gm.),  and 
females  less.  If  the  quantity  eliminated  falls  much  below  this  normal 
minimum,  the  operator  should  be  put  on  his  guard,  and,  when  the 
total  urea  falls  below  100  gr.  (6.5  gm.),  no  one  can  safely  be  given  a 
general  anesthetic  (Fowler).  If  albumin  be  present,  the  dangers  of  a 
general  anesthetic  are  increased,  especially  wdth  ether.  In  the  pres- 
ence of  large  quantities  of  albumin  and  casts  the  operation  should  be 
postponed  or  local  anesthesia  substituted.  With  sugar  in  the  urine, 
the  chances  of  diabetic  coma  developing  should  be  carefully  con- 
sidered. The  presence  of  acetone  and  diacetic  acid  is  of  especial 
dangerous  significance. 

Another  important  point  is  the  arterial  tension.  When  time  per- 
mits, the  blood-pressure  should  be  taken  in  all  cases  (see  Chapter 
III).  If  it  is  found  to  be  abnormally  high,  nitrites  should  be  admin- 
istered for  several  days,  and,  where  there  is  not  time  for  this,  nitro- 
glycerin should  be  given  by  hj-podermic  before  the  anesthetic  is 
begun.  In  the  presence  of  hypotension,  cardiac  stimulants  for  sev- 
eral days  previous  to  the  operation  are  indicated. 

Care  of  the  Patient. — While  the  patient  is  on  the  operating-table 
care  should  be  taken  to  maintain  the  bodily  heat  and  prevent  chilHng 
by  a  proper  amount  of  covering.  The  habit  of  washing  patients  with 
quarts  of  solution  and  leaving  them  lying  in  a  pool  of  chilly  water  is 
to  be  condemned.  It  is  preferable  to  arrange  the  patient  upon  the 
table  before  the  anesthetic  is  begun.  Anesthetizing  a  patient  in  one 
room  and  then  moving  him  to  the  operating-room  is  not,  as  a  rule, 
advisable;  the  lifting  around  of  the  patient  allows  him  to  partly  come 
out,  and  often  starts  up  vomiting. 


PREPARATIONS  FOR  ANESTHESIA  AXD  PRECAUTIONS        5 

The  position  assumed  by  the  patient  upon  the  operating-table 
should  be  unconstrained  and  as  comfortable  as  is  consistent  with  the 
needs  of  the  case.  A  supine  position,  ^\'ith  the  head  elevated  suffi- 
ciently upon  a  small  pillow  to  allow  freedom  in  breathing,  answers  in 
the  majority  of  cases.  Ether  and  nitrous  oxid  may  be  given  with  the 
patient's  head  and  trunk  elevated,  but  great  caution  should  be 
observed  in  administering  chloroform  to  a  patient  sitting  up  or  semi- 
upright,  on  account  of  the  danger  of  cerebral  anemia.  In  weak 
anemic  individuals  the  upright  position  should,  for  the  same  reasons, 
be  avoided  with  anv  anesthetic. 


Fig.  I. — The  anesthetist's  supphes.  i,  Pus  basin;  2,  mouth  wipes  on  artery 
clamps;  3,  mouth  wedge;  4,  tongue  forceps;  5,  mouth  gag;  6,  hypodermic 
syringe. 

Before  administering  the  anesthetic,  anything  that  interferes  with 
or  obstructs  the  respiration  in  the  shghtest  degree  should  be  removed. 
Tight  collars,  bandages  about  the  neck,  clothing,  belts,  straps,  braces, 
etc.,  should  invariably  be  loosened,  no  matter  how  short  the  anes- 
thesia. The  mouth  should  be  examined,  and  false  teeth,  obturators, 
plates,  chewing  gum.  tobacco,  etc.,  should  be  removed  lest  they  fall 
back  into  the  larynx  and  cause  choking.  No  noise  or  talking  should 
be  permitted  in  the  anesthetic  room.  It  is  always  well  to  have  a 
third  person  present  in  case  help  is  needed,  and  in  the  case  of  a  female 
patient  this  is  very  necessary,  as  erotic  dreams  may  lead  to  damaging 
accusations  against  the  anesthetist. 

The  Anesthetist'' s  Supplies. — Besides  the  apparatus  necessary  for 
the  actual  administration  of  the  anesthetic,  the  anesthetist  should 
be  provided  with  the  following:  a  mouth  gag,  a  wedge  or  screw- 


6  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

shaped  piece  of  hard  rubber  to  force  the  jaws  apart,  tongue  forceps, 
a  hypodermic  syringe  in  good  working  order,  with  whisky,  camphor, 
adrenalin,  atropin,  and  strychnin  at  hand,  a  number  of  small  mouth 
wipes  with  an  artery  clamp  as  a  holder,  and  a  small  pus  basin 
(Fig.  i).  A  cylinder  of  oxygen  should  be  ready  for  use,  and  an 
infusion  set  and  tracheotomy  tube  should  be  accessible. 

Duration  of  Anesthesia. — The  anesthetic  should  be  administered 
no  longer  than  is  absolutely  necessary.  It  should  not  be  started  until 
everyone,  including  the  surgeon  and  his  assistants,  is  nearly  ready, 
and  the  completion  of  the  anesthesia  should  be  so  timed  that  the 
patient  is  coming  out  of  it  when  he  leaves  the  table. 


Fig.  2. — Arrangement  of  the  operating-table  and  the  anesthetist's  supplies. 


Stages  of  Anesthesia. — Anesthesia  from  most  of  the  general  anes- 
thetics passes  through  four  stages:  (i)  The  initial,  or  stage  of  irri- 
tation; (2)  the  stage  of  excitement;  (3)  the  stage  of  surgical 
anesthesia;  and  (4)  the  stage  of  coming  out.  With  some  anes- 
thetics the  early  stages  may  be  more  or  less  modified,  or  entirely  ab- 
sent, and  the  rapidity  with  which  the  patient  passes  through  the 
different  stages  depends  upon  the  drug  employed  and  the  technic  of 
its  administration. 

The  Initial  Stage. — The  inhalation  of  anesthetics  like  ether  or 
chloroform  produces  irritation  of  the  mucous  membrane  of  the  respir- 
atory tract  and  a  profuse  secretion  of  mucus  with  some  coughing  and 
frequent  acts  of  swallowing.     To  some  persons,  the  odor  and  taste  of 


PREPARATIONS  POR  ANESTHESIA  AND  PRECAUTIONS        7 

the  anesthetic  are  exceedingly  unpleasant,  so  that  temporary  holding 
of  the  breath  is  not  uncommon.  If  the  vapor  is  given  in  too  concen- 
trated a  form,  violent  coughing  will  be  induced,  accompanied  by 
cyanosis,  and  frequently  a  sense  of  suffocation  is  experienced  and  the 
patient  tries  to  tear  off  the  mask.  If  given  slowly,  the  coughing 
passes  off  and  the  respirations  become  rapid  and  regular.  Spots 
appear  before  the  eyes  and  the  patient  becomes  drowsy.  A  flushed 
face,  rapid  and  full  pulse,  with  hurried  respirations  are  characteristic 
of  this  stage.  The  pupils  dilate,  but  react  to  light,  and  the  cornea 
responds  to  touch.  In  this  stage  the  reflexes  are  increased,  so  that 
a  painful  examination  or  sudden  shock  is  dangerous. 

The  Stage  of  Excitement. — Following  this  preliminary  stage,  the 
patient  rapidly  passes  into  a  condition  of  excitement  or  intoxication. 
His  speech  becomes  incoherent,  and  often  the  imagination  is  excited 
and  hallucinations  occur.  The  patient  begins  to  struggle,  throws  his 
arms  about,  kicks,  tries  to  tear  off  the  mask,  and  frequently  laughs, 
sings,  yells,  cries,  moans,  or  swears.  He  may  breathe  deeply  and 
rapidly,  or  hold  his  breath  and  refuse  to  breathe,  so  that  he  becomes 
markedly  cyanotic.  The  jaws  are  often  held  together  tightly  by  a 
spasm  of  the  masseter  muscles.  Contractions  of  the  muscles  of  the 
trunk  and  extremities  occur.  The  eyes  are  often  rolled  from  side  to 
side.  While  the  patient  usually  hears  those  around  him  talking, 
he  fails  to  understand  what  is  said.  Consciousness  and  sensation  are 
gradually  diminished.  The  pupils  are  still  dilated.  The  pulse  is 
rapid  and  full,  with  very  marked  pulsations  in  the  large  vessels  of  the 
neck. 

Stage  of  Surgical  Anesthesia. — Following  this  period  of  rigidity 
and  excitement,  comes  one  of  general  relaxation.  The  contracted 
muscles  relax;  the  pulse  becomes  slower  and  regular;  the  breathing 
becomes  more  superficial  and  less  hurried,  and  is  accompanied  by  a 
deep  snoring  due  to  the  relaxation  of  the  soft  palate.  The  pupils 
contract  but  still  react  slowly  to  light,  and  the  conjunctival  reflex 
disappears.  The  skin  becomes  cool,  pale,  and  moist.  Total  insen- 
sibility is  now  produced,  and  the  anesthesia  is  complete.  The  loss  of 
the  conjunctival  reflex  is  taken  as  a  sign  that  unconsciousness  is 
present.     This  is  the  time  for  operation. 

The  guide  to  the  depth  of  anesthesia  after  the  disappearance  of 
the  conjunctival  reflex  is  the  condition  of  the  pupils.  With  light 
anesthesia,  the  pupils  are  moderately  contracted  and  readily  react  to 
light;  under  deeper  anesthesia,  the  pupils  are  contracted  and  fail  to 
react  to  light;  and  when  a  very  profound  and  dangerous  stage  of 


8  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

anesthesia  is  established,  the  pupils  dilate  widely  and  remain  so 
without  reaction  to  light,  and  the  respirations  become  shallow  and 
gasping.  In  the  early  stages  of  anesthesia,  and  when  the  patient  is 
coming  out,  the  pupils  also  dilate,  but  they  still  react  to  light  and  the 
corneal  reflex  is  also  present.  After  complete  anesthesia  has  been 
once  reached,  it  may  be  readily  maintained  by  adding  small  amounts 
of  the  anesthetic  from  time  to  time;  just  enough  should  be  adminis- 
tered to  keep  the  pupils  midway  between  contraction  and  dilatation, 
with  a  response  to  Hght  at  all  times. 

Stage  of  Recovery. — The  recovery  from  the  anesthetic  is  character- 
ized by  the  occurrence  of  these  same  stages  in  reverse  order.  In 
some  cases  the  recovery  is  more  rapid  than  in  others.  The  breathing 
becomes  slower  and  less  audible,  and  there  is  frequent  sighing.  The 
conjunctival  reflex  reappears,  the  pupillary  reflex  becomes  active, 
and  the  patient  rolls  the  eyes  about.  Frequent  swallowing  occurs, 
followed  by  retching.  Vomiting  of  frothy  and  often  bile-stained 
mucus  is  present  in  most  cases,  and  may  be  continued  for  an  hour  or 
more.  Partial  consciousness,  wath  laughing,  crying,  or  incoherent 
speech  follow,  and  it  is  usually  some  hours  before  the  mental  equilib- 
rium is  completely  regained.  Hyperesthesia  is  marked  in  the  period 
of  recovery,  and  general  irritabiHty.  complaints  of  discomfort,  and 
pain  are  to  be  expected.  Some,  however,  especially  children,  pass 
nto  a  deep  sleep  lasting  for  several  hours. 

ETHER  ANESTHESIA 

Ether  is  a  very  volatile,  colorless  liquid,  with  a  strong,  pungent 
odor  and  a  burning,  sweetish  taste.  It  is  very  inflammable,  and 
should  not  be  used  near  a  flame,  cautery,  or  an  X-ray  tube.  An 
artificial  light  held  well  above  it  is  safe,  however,  as  the  ether  fumes 
tend  to  sink  downward.  Only  the  purest  ether  should  be  used  for  an- 
esthetic purposes,  and  it  should  be  kept  in  hermetically  sealed  tin 
cans,  as  exposure  to  hght  and  air  cause  it  to  decompose  into  acetic 
acid  and  other  irritating  products. 

Ether  fumes,  when  inhaled,  prove  very  irritating  to  the  mucous 
membranes  of  the  nose,  mouth,  and  respiratory  tract,  and  produce 
an  increased  secretion  of  mucus  and  sahva,  often  accompanied  by 
coughing.  Lesions  of  the  lungs  are  thus  apt  to  follow  its  use,  and  may 
be  due  to  the  aspiration  of  saHva  as  well  as  to  the  direct  irritation  of 
the  ether  vapor.  Ether  is  a  distinct  cardiac  stimulant,  accelerating 
the  heart  action  and  raising  blood-pressure;  this  effect  is  well  shown 


ETHER    ANESTHESIA  9 

when  ether  is  administered  to  a  very  ill  person,  the  character  of  the 
pulse  often  being  improved  immediately  and  continuing  so  until  the 
end  of  the  anesthesia.  While  its  primary  effect  is  one  of  stimulation, 
in  toxic  doses  it  acts  as  a  depressant,  especially  upon  the  respiratory 
centers.  It  is  estimated  that  ether  is  about  five  times  as  safe  as 
chloroform,  and,  as  it  is  less  rapid  in  its  action,  danger  signs  can  be  rec- 
ognized and  proper  treatment  instituted  with  more  chances  of  success 
than  with  the  latter.  Upon  the  kidneys  it  acts  as  an  irritant,  andpro- 
longed  anesthesia  often  results  in  postoperative  albuminuria.  Ether 
produces  a  distinct  leukocytosis,  a  slight  diminution  of  the  hemoglobin, 
and  a  marked  decrease  in  the  coagulation-time  of  the  blood  (Ham- 
burger and  Ewing).  According  to  Graham  the  phagocytic  power  of 
the  blood  is  reduced  after  an  ordinary  ether  anesthesia. 

Owing  to  its  low  boiling-point  and  volatility,  ether  is  very  rapidly 
eliminated  from  the  lungs,  and  it  is  necessary  to  give  it  in  a  more  or 
less  concentrated  form,  thus  differing  from  the  administration  of 
chloroform.  The  administration  of  ether  is  rendered  safer  if  prelimi- 
nary anesthesia  is  induced  by  some  quick  anesthetic,  as  nitrous  oxid 
or  ethyl  chlorid;  furthermore,  oxygen  and  ether  is  a  safer  mixture 
than  air  and  ether.  The  oxygen  may  be  administered  by  passing  the 
oxygen  tube  under  the  mask,  or,  in  the  closed  inhalers,  the  tube  may 
be  attached  directly  to  the  ether  bag. 

Suitable  Cases. — When  a  general  anesthetic  is  necessary  and  the 
operation  is  not  suited  to  nitrous  oxid  anesthesia,  ether  is  preferable 
to  chloroform  unless  direct  contraindications  to  its  use  are  present. 
In  the  hands  of  an  expert,  many  of  the  dangers  attributed  to  chloro- 
form are  absent,  but  it  must  be  remembered  that  under  the  same 
conditions  ether  is  also  less  dangerous.  In  unskilled  hands,  how- 
ever, there  can  be  no  doubt  that  ether  is  always  the  safer. 

For  the  stimulating  effects  in  cases  of  shock  or  hemorrhage,  or 
when  it  is  necessary  to  obtain  a  profound  degree  of  narcosis  with 
abohtion  of  the  reflexes,  ether  is  by  all  means  the  best  agent  to  use. 
In  anemia  ether  is  preferable  to  chloroform,  as  it  has  less  marked  an 
effect  upon  the  hemoglobin.  If  the  patient's  hemoglobin  is  below  30 
per  cent.,  however,  any  general  anesthetic  is  contraindicated  (Da 
Costa).  In  heart  disease,  if  the  compensation  is  good,  ether  is  safe, 
but  with  broken  compensation  or  when  there  is  high  arterial  tension 
and  degenerative  changes  in  the  blood-vessels,  it  is  contraindicated 
on  account  of  the  danger  from  overstimulation.  In  myocardial 
disease  it  is  unsafe,  but  not  so  dangerous  as  is  chloroform. 

On  account  of  its  irritant  action,   ether  should  be  avoided  in 


lO 


THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS 


bronchitis  or  acute  lung  troubles,  and,  for  the  same  reason,  in 
advanced  Bright's  disease.  In  patients  over  sLxty  years  old,  ether, 
as  a  rule,  is  to  be  avoided,  as  they  are  very  likely  to  be  afflicted  with 
respiratory  troubles,  and  the  circulatory  system  is  usually  the  seat  of 
degenerative  changes.  For  children,  a  mixture  of  chloroform  and 
ether,  or  chloroform  alone,  is  the  better  anesthetic,  ether  proving 
irritating  to  the  delicate  respiratory  mucous  membrane  of  a  child, 
and  often  producing  such  a  flow  of  mucus  and  saliva  that  breathing  is 
seriously  interfered   with. 

Ether  is  not  recommended  in  cerebral  operations — at  the  begin- 
ning, at  any  rate — on  account  of  the  struggling,  resultant  conges- 
tion,   and   increased   liability    to   hemorrhage.     It   should   never   he 


Fig.  3. — The  Esmarch  mask. 


administered  in  operations  about  the  mouth  or  face  requiring  the  use 
of  a  cautery  near  by. 

Apparatus. — Ether  may  be  satisfactorily  administered  by  the  drop 
method,  the  semiopen,  the  closed,  or  the  vapor  method.  Different 
forms  of  inhalers  are  used,  according  to  which  method  is  employed. 
Of  the  open  inhalers,  any  of  the  chloroform  masks,  such  as  Esmarch's 
(Fig.  3)  or  Schimmelbusch's  (Fig.  4),  will  be  found  satisfactory. 
They  are  very  simple,  consisting  of  a  wire  frame  covered  with  canton 
flannel  or  several  layers  of  gauze,  upon  which  the  ether  is  dropped. 
Such  inhalers  permit  a  very  plentiful  supply  of  air.  An  ordinary 
chloroform  bottle  (Fig.  5)  may  be  used  for  the  dropping,  or  a  very 
convenient  dropper  may  be  improvised  by  cutting  a  groove  in 
opposite  sides  of  the  cork  of  the  ether  can — one  to  admit  air  and  the 
other  to  allow  the  escape  of  the  ether. 

The  Allis  inhaler  (Fig.  6)  is  a  type  of  the  semiopen  cone.     It 


ETHER   ANESTHESIA 


II 


consists  of  an  outer  rubber  case  in  the  upper  part  of  which  is  fitted 
a  metal  frame  provided  with  slits  through  which  is  threaded  a  cotton 
or  flannel  bandage.  A  very  simple  semiopen  inhaler  may  be  made  by 
rolling  several  thicknesses  of  heavy  brown  paper  into  a  cuff  and 


Fig.  4. — The  Schimmelbusch  mask. 


Fig.  5. — Chloroform  dropper. 


covering  it  with  a  towel.  The  top  of  the  cone,  which  is  held  partly 
closed  by  safety  pins,  is  filled  with  gauze  upon  which  the  ether  is 
poured  (Fig.  7). 

There  are  many  excellent  closed  inhalers,   such  as  the  Clover 
(Fig.  8),  the  Bennet  (Fig.  9),  the  Gwathmey,  the  Pedersen,  etc.  These 


Fig.  6.— The  AlHs  inhaler. 

consist  essentially  of  a  metal  face-piece  surrounded  by  an  inflatable 
rubber  rim,  an  ether  chamber  filled  with  gauze,  and  a  closed  rubber 
bag  into  and  out  of  w^hich  the  patient  breathes.  They  are  also  pro- 
vided with  suitable  openings  for  the  entrance  of  air.^     With  such 

1  Space  does  not  permit  a  detailed  description  of  these  inhalers,  nor  is  it  necessary, 
as  a  description  of  the  mechansim  and  full  instructions  are  furnished  with  each 
instrument. 


12 


THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 


inhalers,  the  temperature  of  the  ether  vapor  is  raised  by  the  expired 
air  and  the  supply  of  carbon  dioxid,   the  normal  stimulant  of  the 
respiratory  and  cardio-vascular  centers,  is  maintained  through  the 
rebreathing,  thus  adding  to  the  value  and  safety  of  the  anesthetic. 
To  obtain  the  benefit  of  the  warm  vapor  without  the  disad- 


FiG.  7. — Towel  cone. 

vantages  of  the  closed  inhalers,  the  vapor  method  of  etherization  is 
preferred  by  some.  It  is  an  excellent  method  of  anesthesia  to  use  in 
operations  about  the  mouth,  as  the  vapor  can  be  delivered  through  a 
small  tube  passed  into  the  mouth  without  interfering  with  the  opera- 
tion.    There  are  a  number  of  inhalers  for  this  purpose,  of  which 


Fig.  8. — The  Clover  ether  inhaler. 

Gwathmey's  apparatus  is  a  type.  Gwathmey's  vapor  apparatus 
(Fig.  10),  as  described  by  him  {Journal  of  American  Medical  Associa- 
tion, October  27,  1906),  consists  of  two  six-ounce  (180  c.c.)  bottles,  one 
for  chloroform  and  one  for  ether.  Both  bottles  are  placed  in  a  tin 
vessel  containing  thermolite.     This  ''  thermolite  warmer,"  if  placed  in 


ETHER    ANESTHESIA 


13 


boiling  water  for  three  minutes,  will  remain  warm  for  over  one  and  a 
half  hours.  If  the  heat  is  to  be  continued,  this  can  be  accompHshed 
by  simply  taking  the  stoppers  out,  thus  exposing  the  thermolite  to  the 
atmosphere.  The  liquid  then  begins  to  recrystallize,  and  on  turning 
to  a  sohd  form  gives  off  heat  for  another  hour  and  a  half.     In  each  of 


Fig.  9.— The  Bennet  ether  inhaler. 

the  bottles  there  are  three  tubes,  varying  in  length  from  one  that 
reaches  to  the  bottom  of  the  bottle  to  one  that  penetrates  only  the 
stopper,  and  representing  three  degrees  of  vapor  strength.  The  small 
switches  at  the  top  of  each  bottle  are  so  arranged  that  chloroform 
or  ether  can  be  given,  combined  or  separately,  and  in  any  strength 


Fig.   10. — Gwathmey's  vapor  apparatus. 

desired.  In  addition,  by  simply  turning  a  small  lever,  without 
removing  the  mask,  the  patient  receives  pure  air  or  a  mixture  of  oxy- 
gen and  air.  By  compressing  the  hand  bulb,  air  or  oxygen  is  forced 
into  the  apparatus  and  the  warmed  ether  or  chloroform  vapor  is 
carried  to  the  patient  by  the  efferent  tube. 

Inhalers,    whatever    the    variety,    should    always   be    sterilized 


14 


THE   ADMINISTRATION    OF   GENERAL   ANESTHETICS 


after  use.  Disregard  of  this  precaution  has  been  the  cause  of 
many  of  the  cases  of  postoperative  pneumonia.  Metal  portions  of 
the  inhaler  should  be  boiled  and  the  rubber  parts  soaked  in  a  i  to  20 
solution  of  carboUc  acid  after  each  administration.  The  parts  are 
then  dried,  and  fresh  gauze  packing  is  suppHed  for  the  closed  inhalers 
and  the  open  ones  are  covered  with  new  gauze  or  canton  flannel. 

Administration. — Drop  Method. — The  usual  precautions  ahead}- 
detailed  having  been  observed,  and  the  eyes  of  the  patient  being 
protected  by  a  folded  piece  of  gauze,  the  mask  is  placed  over  the 
mouth  wiih.  the  request  that  the  patient  breathe  naturally  and  regu- 


FlG.   II. — Showing  the  administration  of  ether  by  the  drop  method. 

larly.  As  soon  as  several  breaths  have  been  taken,  a  few  drops  of 
ether  are  poured  upon  the  mask.  After  a  few  more  breaths,  more 
ether  is  added,  gradually  increasing  the  amount  each  time.  If  the 
patient  struggles  or  begins  to  cough  and  choke,  the  amount  of  ether 
should  be  lessened  for  the  time  being.  In  from  five  to  six  minutes  the 
stage  of  excitement  and  struggb'ng  begins,  and  the  ether  should  then 
be  dropped  more  rapidly.  Large  amounts  should  never  be  poured 
on  suddenly,  however,  as  this  simply  irritates  the  respiratory 
tract  and  produces  laryngeal  spasm,  causing  the  patient  to  cough, 
choke,  or  hold  his  breath.  If  the  dropping  is  properly  performed, 
full  anesthesia  should  be  obtained  in  from  ten  to  fifteen  mintues.  By 
the  drop  method  an  even  anesthesia  without  cyanosis  is  produced. 


ETHER   ANESTHESIA  1 5 

As  soon  as  the  patient  is  thoroughly  anesthetized,  just  sufficient  ether 
should  be  given  to  keep  him  thoroughly  under  its  effects. 

During  the  anesthesia  the  breathing  should  be  carefully  watched, 
together  with  the  pulse  and  the  eye  reflexes.  Under  the  stimulation 
of  the  ether,  the  respirations  are  increased  in  frequency  and  depth, 
and  are  rather  noisy  in  character  on  account  of  the  increased  amount 
of  mucus  and  saliva  that  collects  in  the  throat.  Irregular  rapid 
respiration  approaching  a  gasping  type  is  unsafe.  The  breathing 
should  not  be  allowed  to  become  gurgling  or  obstructed.  To  prevent 
this,  the  jaw  should  be  held  well  forward  by  placing  the  fingers  back 
of  the  angle,  as  shown  in  the  accompanying  illustration  (Fig.  12). 
This  prevents  the  relaxed  epiglottis  from  being  forced  back  by  the 
tongue  over  the  opening  in  the  larynx,  since,  if  the  jaw  is  pushed  for- 
v/ard,  the  tongue  goes  with  it,  giving  a  clear  passage.     In  holding  the 


Fig.   12. — Proper  method  of  holding  the  jaw  forward. 

jaw  forward,  care  should  be  taken  not  to  use  force  or  bruise  the 
tissues.  If  this  maneuver  does  not  overcome  the  obstruction  from 
the  tongue,  the  latter  should  be  pulled  out  and  held  well  forward  by 
means  of  a  tongue  forceps  or  a  silk  thread  passed  through  its  tip. 
This,  however,  is  seldom  necessary  if  the  jaw  is  properly  held  and  the 
head  is  turned  to  one  side  so  as  to  ailow  the  mucus  and  saliva  to  flow 
out  through  the  corner  of  the  mouth.  Should  vomiting  occur,  the 
inhaler  must  be  removed  and  the  patient's  head  turned  to  one  side  so 
that  the  vomited  matter  can  escape;  and,  before  the  mask  is  reap- 
pHed,  the  mouth  should  be  well  cleared  of  vomitus. 

The  pulse  under  the  effect  of  ether  becomes  somewhat  rapid,  but 
of  greater  volume  and  increased  tension.  At  first  the  pupils  are 
widely  dilated  and  then  tend  to  moderately  contract.  Should  they 
suddenly  dilate  and  remain  so  without  responding  to  hght  in  the 
absence  of  the  conjunctival  reflex,  it  is  a  sign  of  overnarcosis.  Other 
danger  signs  are  a  weak,  thready,  or  irregular  pulse,  and  marked  pallor 


1 6  THE   ADMINISTRATION    OF    GENERAL   ANESTHETICS 

or  cyanosis.  Hiccough  usually  means  that  the  patient  is  getting 
ready  to  vomit.  Rolling  of  the  eyes  and  repeated  acts  of  swallowing 
are  preliminaries  to  the  patient  coming  out.  Both  conditions  require 
more  ether. 

As  the  operation  progresses,  smaller  quantities  of  ether  should  be 
used,  and  the  anesthesia  should  be  so  regulated  that  the  patient  will 
be  just  coming  out  by  the  time  that  he  is  ready  to  be  moved  from  the 
table.  The  amount  of  ether  used  will  depend  upon  the  skill  of  the 
anesthetist  and  the  form  of  inhaler.  With  the  open  inhaler,  from 
two  to  four  ounces  (60  to  120  c.c.)  should  suffice  for  an  hour;  in 
the  closed  inhalers,  much  less  will  be  consumed.  It  should  always 
be  the  aim  of  the  anesthetist  to  use  just  as  little  as  may  be  necessary 
to  keep  the  patient  under  control. 

Semiopen  Method. — Etherization  with  a  semiopen  inhaler  differs 
in  no  material  way  from  the  drop  method.  The  anesthesia  should  be 
started  slowly  by  pouring  into  the  top  of  the  cone  small  quantities 
of  ether  at  a  time.  After  complete  anesthesia  is  obtained,  it  may  be 
maintained  by  the  use  of  less  ether  than  with  the  drop  method,  as  the 
ether  does  not  volatilize  so  rapidly. 

Closed  Method. — The  gauze  in  the  ether  chamber  is  well  saturated 
with  ether  before  commencing  the  anesthesia.  The  cone  is  then 
apphed  and  the  patient  is  instructed  to  take  regular  breaths,  breath- 
ing back  and  forth  through  the  bag.  As  soon  as  he  becomes  accus- 
tomed to  the  apparatus,  ether  is  slowly  turned  on  during  an  inspira- 
tion by  gradually  revolving  the  drum  of  the  ether  chamber  (Fig.  13). 
If  cough  or  signs  of  irritation  occur,  the  amount  of  ether  should  be 
cut  down.  Care  should  always  be  taken  not  to  push  the  anesthetic  too 
fast.  As  the  patient  breathes  into  and  out  of  the  rubber  bag,  it 
should  be  seen  that  the  latter  is  kept  about  two-thirds  full  of  air — it 
should  never  be  allowed  to  become  empty.  Usually  with  a  closed 
inhaler  anesthesia  can  be  produced  in  from  four  to  six  minutes.  On 
account  of  rebreathing  the  same  air,  some  duskiness  of  countenance  is 
to  be  expected,  but  this  may  be  regulated  by  admitting  more  air  or  by 
administering  oxygen.  A  distinct  livid  color  should  not  be  allowed  to 
persist  with  either  a  closed  or  an  open  inhaler.  Such  a  condition  is  a 
sign  of  poor  administration  of  the  anesthetic,  or  else  the  particular 
anesthetic  used  is  not  suited  to  the  case. 

Anesthesia  by  the  closed  method,  besides  being  more  rapid, 
reduces  considerably  the  amount  of  ether  used.  Recovery  from  the 
effects  of  the  anesthesia  is  more  prompt,  and  the  after-effects,  as 
nausea  and  vomiting,   are  greatly   diminished.     Furthermore,   the 


CHLOROFORM    ANESTHESIA 


17 


ether  vapor  inhaled  from  the  bag,  being  warm,  is  safer,  more  effective, 
and  less  apt  to  produce  irritation  of  the  respiratory  tract. 

Vapor  Method. — It  is  preferable  to  start  the  anesthesia  by  some 
of  the  quick  methods,  as  nitrous  oxid  gas  followed  by  ether,  or  by 
ethyl  chlorid  followed  by  ether,  and,  when  the  patient  is  well  under 
its  influence,  the  ether  vapor  is  substituted.  The  vapor  method  may, 
however,  be  used  from  the  beginning,  if  desired,  starting  with  a  me- 
dium percentage  of  vapor,  and  then  working  to  the  highest.     When 


Fig.   13. — Showing  the  administration  of  ether  with  a  closed  inhaler. 

completely  under,  a  medium  or  low  percentage  of  vapor  is  used, 
according  to  the  depth  of  anesthesia  desired.  The  mask  used  in  this 
method  is  covered  with  gauze,  over  which  an  impermeable  material, 
as  rubber  tissue  or  oil  silk  is  placed,  with  a  small  opening  in  the  center 
about  the  size  of  a  ten-cent  piece,  through  which  additional  anesthetic 
may  be  dropped  if  it  is  found  to  be  difficult  to  induce  narcosis  with 
the  vapor  alone. 

The  vapor  method  gives  a  light  anesthesia,  just  abolishing  the 
reflexes.  The  breathing  more  nearly  approaches  the  normal,  with- 
out the  snoring  rapid  respiration  usual  to  ether.  The  pulse  is 
nearer  normal,  and  the  duskiness  of  countenance  often  present 
with  the  closed  method  is  absent. 

CHLOROFORM  ANESTHESIA 

Chloroform  is  a  clear,  colorless,  heavy,  volatile  liquid  with  a  sweet- 
ish taste  and  characteristic  odor.     When  used  for  anesthetic  purposes. 


15  THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS 

it  should  be  absolutely  pure  and  neutral  to  litmus.  Under  the  influ- 
ence of  heat  or  light,  it  decomposes  into  hydrochloric  acid,  chlorin, 
etc.,  hence  it  should  always  be  kept  in  well-stoppered,  dark  amber- 
colored  bottles  and  in  a  cool  place.  It  is  more  irritating  to  the  skin 
than  ether  and,  if  confined,  will  produce  bhsters.  For  this  reason  the 
lips,  nose,  and  cheeks  with  which  it  may  come  in  contact  during 
anesthesia  should  be  well  protected  with  vaselin. 

When  inhaled,  chloroform  vapor  has  a  depressant  effect  upon  all 
the  vital  functions,  but  especially  upon  the  circulation, lowering 
blood-pressure  to  a  marked  degree  through  vasomotor  depression. 
It  is  less  of  an  irritant  to  the  respiratory  tract  and  more  agreeable  to 
take  than  ether,  hence  the  primary  stage  of  excitement  is  milder. 
Upon  the  kidneys,  it  is  likewise  less  irritating.  It  causes  slight  tem- 
porary fatty  changes  in  the  kidneys,  heart  muscle,  and  liver  (more 
marked  upon  the  latter)  which  may  be  severe  and  later  lead  to  fatal 
results  if  these  organs  are  already  diseased. 

Death  from  chloroform  is  usually  sudden  and  without  premoni- 
tory signs.  Vasomotor  paralysis  causing  dilatation  of  the  vessels 
and  capillaries  and  fatal  syncope  is  the  primary  cause,  though  the 
inhiditory  action  of  the  drug  upon  the  heart  itself  may  contribute. 
Respiratory  failure  is  not  common  as  a  primary  complication,  but  is 
secondary  to  the  failure  of  the  vasomotor  centers.  Many  of  the 
deaths  from  chloroform  occur  early  in  its  administration  when,  during 
the  stage  of  excitement  and  struggling,  more  of  the  drug  is  inhaled 
than  is  expected,  or  it  is  pushed  too  rapidly  in  an  attempt  to  overcome 
the  struggHng.  With  a  trained  and  watchful  assistant  as  an  anes- 
thetist, chloroform  is  robbed  of  many  of  its  dangers,  but  in  inex- 
perienced hands  it  is  a  most  dangerous  drug,  being  estimated  to  be 
about  five  times  more  fatal  than  ether. 

Chloroform  is  the  strongest  anesthetic  we  possess,  and  should 
always  be  administered  well  diluted  with  air.  A  stronger  vapor  than 
2  per  cent,  is  a  dangerous  dose.  In  this  respect  it  differs  from  nitrous 
oxid  and  ether,  in  the  use  of  which  a  well-saturated  vapor  is  required. 
A  mixture  of  chloroform  and  oxygen  is  safer  than  chloroform  and  air. 
The  use  of  this  combination  is  less  often  accompanied  by  circulatory 
depression,  while  cyanosis  and  postoperative  vomiting  are  less  fre- 
quent. 

Chloroform  should  always  be  administered  warm.  This  can  be 
accompUshed  by  using  some  one  of  the  warm  vapor  inhalers,  or  by 
simply  placing  the  bottle  containing  the  drug  in  warm  water  (ioo° 
F.,  38°  C.)  every  few  moments. 


CHLOROFORM    ANESTHESIA  I9 

Chloroform  should  not  be  given  with  the  head  very  high,  or  with 
the  patient  sitting  up,  on  account  of  the  danger  of  syncope;  this 
precaution  should  also  be  borne  in  mind  when  lifting  or  moving  per- 
sons under  the  influence  of  chloroform.  As  a  rule,  the  recovery  from 
chloroform  anesthesia  is  quicker  than  from  ether,  though  the  vomit- 
ing may  last  longer. 

Suitable  Cases. — Chloroform  is  generally  preferred  to  ether  in 
young  children  and  in  those  over  sixty  years  of  age  who  are  free  from 
myocardial  disease,  for  the  reason  that  it  causes  less  irritation  of 
the  respiratory  tract.  It  is  preferred  to  ether  for  patients  with 
advanced  Bright' s  disease  who  are  free  from  myocardial  trouble,  in 
obstructive  conditions  of  the  larynx  or  trachea,  and  for  those  whose 
lungs  are  involved  by  such  conditions  as  tuberculosis,  asthma, 
bronchitis,  etc. 

In  heart  disease  with  broken  compensation  and  dyspnea,  in 
aneurysm,  and  in  cases  of  marked  degeneration  of  the  blood- 
vessels, chloroform  is  better  than  ether  on  account  of  the  milder 
preliminary  stages.  In  cases  of  myocarditis  and  of  fatty  degeneration 
it  is  dangerous  and  some  other  drug  should  be  employed. 

In  parturition  it  is  safer  than  in  health,  because  only  a  partial 
action  is  required,  and  fright  and  apprehension  which  may  be  the 
cause  of  some  of  the  fatalities  are  absent.  When,  however,  deep 
surgical  anesthesia  is  required  in  such  cases,  ether  is  indicated. 
In  eclampsia  chloroform  should  not  be  used  on  account  of  its  destruc- 
tive action  upon  the  liver.  In  fact,  in  the  presence  of  any  liver  lesion 
it  should  be  avoided. 

Chloroform  should  be  avoided  as  an  anesthetic  in  hemorrhage  or 
shock,  on  account  of  its  depressant  effect  upon  the  circulation;  and 
likewise  in  anemia,  as  it  decreases  hemoglobin.  In  cerebral  surgery, 
chloroform  is  preferred  by  many  surgeons,  and  also  in  operations 
about  the  face  and  mouth,  as  it  causes  but  little  cough  and  flow  of 
saliva,  and  the  anesthesia  can  be  maintained  with  but  a  small 
amount  of  anesthetic.  As  its  vapor  is  not  inflammable,  it  can  be 
employed  in  operations  about  the  mouth  or  face  while  the  cautery 
is  being  used.  In  minor  surgical  cases,  where  the  operation  is 
often  performed  under  incomplete  anesthesia,  chloroform  is  con- 
traindicated.  In  ophthalmic  operations,  where  the  condition  of 
the  pupil  cannot  be  ascertained,  ether  is  preferred  to  chloroform. 

Apparatus. — Chloroform  should  never  be  administered  in  a  closed 
inhaler.  Either  the  open  drop  method,  with  a  free  mixture  of  air,  or 
the  warm  vapor  method  should  be  employed.     For  the  former,  a 


20 


THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS 


handkerchief,  the  corner  of  a  towel  (Fig.  14),  or  a  piece  of  gauze  will 
suffice,  but  a  mask,  such  as  Skinner's,  Esmarch's  (see  Fig.  3),  or 
Schimmelbusch's  (see  Fig.  4),  covered  with  canton  flannel  or  several 
layers  of  gauze,  is  more  suitable.  In  addition,  a  drop  bottle  (see 
Fig.  5)  from  which  the  flow  can  be  accurately  regulated,  and  a  recep- 
tacle for  warm  water  will  be  required. 


Fig.   14. — Chloroform  mask  improvised  from  the  corner  of  a  towel. 

Different  forms  of  apparatus  for  accurately  estimating  the 
strength  of  vapor,  as  Junker's  (Fig.  15),  Braun's,  Gwathmey's  (see 
Fig.  10),  etc.,  are  often  used.  These  are  supplied  with  a  tracheal 
tube  and  are  especially  useful  in  operations  about  the  mouth  or  throat. 
By  squeezing  the  bulb,  air  is  forced  through  the  warmed  chloroform, 
and  a  vapor  containing  a  definite  mixture  of  chloroform  and  air  is 
administered.     By  attaching  the  bulb  to  a  tube  connected  with  an 


Fig.   15. — Junker's  chloroform  inhaler. 

oxygen  cylinder,  oxygen  may  be  readily  administered  instead  of  air. 

The  same  care  as  to  the  cleanhness  of  the  chloroform  mask  should 
be  observed  as  would  be  with  ether  inhalers.  After  each  anesthesia 
the  metal  framework  should  be  boiled  and  then  recovered. 

Administration. — The  patient's  lips,  nose,  mouth,  and  cheeks 
should  be  well  greased  with  vaselin  or  lanolin.  The  anesthetic  is 
started  by  holding  the  mask  wet  with  a  few  drops  of  warm  chloro- 


CHLOROFORil    AXESTHESLA. 


21 


form  4  or  5  inches  (lo  to  12  cm.)  from  the  face  (Fig.  16),  the  patient 
being  told  to  breathe  naturally  and  regularly.  As  soon  as  the  patient 
grows  accustomed  to  the  vapor,  the  chloroform  is  dropped  steadily  at 
a  rate  of  10  to  30  drops  a  minute,  and  the  mask  is  brought  nearer  the 
face,  being  careful,  ho^Yever,  not  to  touch  the  skin  with  portions  of 
the  mask  wet  with  chloroform  (Fig.  17).  When  given  gradually  in 
this  way,  the  struggHng  is  not  usually  prolonged  or  violent.  The 
anesthetic  should  never  be  poured  on  suddenly  in  large  quantities; 
it  must  always  be  administered  well  diluted  with  air.  In  the  stage  of 
excitement,  chloroform  must  he  given  with  extreme  care;  if  the  patient 


Fig.   16. — Showing  the  method  of  administering  chloroform  (first  step). 

struggles,  the  drug  should  not  be  pushed,  otherwise,  when  the  patient 
holds  his  breath,  as  he  will  in  such  cases,  a  large  quantity  of  the  anes- 
thetic is  retained  in  the  lungs,  and,  when  he  takes  a  deep  breath,  a 
dangerous  amount  may  be  inhaled  from  the  aheady  oversaturated 
mask.  Coughing  and  vomiting  mean  that  the  vapor  is  too  strong, 
and  it  should  be  promptly  diluted  as  it  should  also  if  the  patient's 
breathing  becomes  embarrassed.  The  jaw  must  be  kept  well  forward 
if  there  is  the  slightest  impediment  from  the  tongue  to  free  respiration. 
When  the  patient  is  fully  anesthetized,  only  smaU  quantities  of  the 
anesthetic  should  be  administered,  just  sufficient  to  keep  him  under. 
With  chloroform  anesthesia,  we  have  practically  the  same  stages 


22 


THE   ADMINISTRATION   OF    GENERAL  ANESTHETICS 


as  with  ether.  l)ut  the)-  succeed  each  other  more  rapidly,  and  a  dan- 
gerous degree  of  anesthesia  is  quickly  produced  unless  proper 
care  be  taken.  The  stage  of  excitement  is  less  marked  and  shorter 
than  with  ether,  and  the  patient  presents  a  more  tranquil  appearance 
in  every  way.  It  should  be  the  aim  of  the  anesthetist  to  keep  the 
patient  in  about  the  following  condition:  regular  and  fairly  deep 
respirations,  with  only  a  slight  snore;  pupils  moderately  contracted 
and  sluggishly  sensitive  to  hght;  conjunctival  reflex  just  aboHshed; 
full  muscular  relaxation;  and  a  good  color  without  blueness  of  the 
lips  or  cheeks.     The  latter  is  an  indication  for  a  weaker  vapor  and 


Fig.   17. — Showing  the  method  of  administering  chloroform  (second  step). 

more  air  or  oxygen.  With  the  ordinary  chloroform  mask,  oxygen 
may  be  administered  by  simply  inserting  the  tube  leading  from  the 
oxygen  cylinder  under  the  edge  of  the  mask. 

During  the  entire  anesthesia,  careful  and  close  watch  should  be 
kept  over  the  respirations,  the  pulse,  the  condition  of  the  eye  reflexes, 
and  the  general  appearance  of  the  patient.  It  is  only  by  the  constant 
and  undivided  attention  of  the  anesthetist  that  the  safety  of  the 
patient  can  be  guaranteed.  The  slightest  alteration  in  the  respira- 
tions should  be  taken  as  a  warning,  as  this  is  often  the  precursor  to 
circulatory  failure.  Very  shallow,  irregular,  or  gasping  respiration,  a 
weak,  thready,  or  intermittent  pulse,  sudden  and  continued  dilatation 


NITROUS    OXID    ANESTHESIA  23 

of  the  pupils  In  the  absence  of  eye  reflexes,  and  marked  duskiness  or 
sudden  pallor  of  the  skin,  are  all  indications  that  a  dangerous  stage 
of  narcosis  has  been  reached. 

The  administration  of  anesthetics  by  the  vapor  method  has 
already  been  described  under  ether  anesthesia  (page  17),  and  will  not 
be  repeated  here.  With  chloroform,  it  is  an  especially  valuable 
method  to  employ,  as  the  warm  vapor  may  be  administered  in  a  defi- 
nite strength,  and  with  air  or  oxygen  as  desired. 

NITROUS  OXID  ANESTHESIA 

Nitrous  oxid  is  a  colorless  gas,  heavier  than  air,  and  with  no  per- 
ceptible odor  or  taste.  It  is  obtained  in  a  liquid  form,  highly  com- 
pressed in  steel  cyUnders  or  containers,  from  which,  when  liberated, 
it  escapes  as  a  gas.  It  has  marked  anesthetic  properties,  though  the 
anesthesia  is  not  so  profound  as  that  from  ether  or  chloroform.  It 
increases  the  rate  and  depth  of  respiration  and  accelerates  the  heart 
action,  at  the  same  time  raising  blood-pressure.  If  pushed  too  far, 
the  respirations  cease,  though  the  heart  continues  to  beat  for  some 
time.  For  short  operations  it  is  the  safest  of  all  the  general  anes- 
thetics, I  in  100,000  being  the  generally  accepted  death  rate. 

Anesthesia  from  nitrous  oxid  cannot  be  maintained  for  more 
than  fifty  or  sixty  seconds  without  air,  on  account  of  the  develop- 
ment of  symptoms  of  asphyxiation.  Used  with  the  proper  admix- 
ture of  air  or  oxygen,  however,  an  anesthesia  for  an  hour  or  more 
may  be  safely  maintained.  According  to  Hewitt,  mixtures  con- 
taining 5  to  7  per  cent,  of  oxygen  are  best  suited  for  adult  males,  and 
mixtures  of  7  to  9  per  cent,  of  oxygen  are  best  for  females  and  chil- 
dren. Mixtures  of  nitrous  oxid  and  air,  composed  of  from  14  to  18 
per  cent,  of  the  latter  for  men,  and  from  18  to  22  per  cent,  for  women, 
give  the  next  best  results. 

Nitrous  oxid  is  very  rapid  in  its  action,  producing  complete 
unconsciousness  in  from  one  to  two  minutes,  and  is  the  most  agree- 
able of  the  general  anesthetics  to  take.  The  patient  comes  out  of  it 
very  quickly,  usually  in  from  thirty  to  sixty  seconds,  and  its  use  is 
not  followed  by  nausea  and  vomiting.  The  lung,  kidney,  and  heart 
complications  of  ether  and  chloroform  are  likewise  absent. 

Suitable  Cases. — When  used  pure,  nitrous  oxid  is  suitable  only 
for  short  procedures  lasting  about  a  minute,  such  as  extracting  teeth 
and  making  incisions  for  drainage,  etc. 

With  the  admixture  of  air  or  oxygen  in  proper  quantities  to  pre- 
vent asphyxial  symptoms,  and  administered  by  an  expert,  it  may  be 


24  THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS 

made  applicable  for  anesthesia  in  some  major  surgical  operations 
not  consuming  a  great  deal  of  time,  as  well  as  in  many  of  the  minor 
ones.  It  is  an  excellent  anesthetic  to  employ  for  the  reduction  of 
fractures  requiring  only  a  moderate  amount  of  muscular  relaxation, 
and  for  breaking  up  adhesions  in  ankylosed  joints.  When  local  anes- 
thesia is  contraindicated,  it  becomes  the  anesthetic  of  choice  for 
abscess,  felon,  empyema,  benign  tumors,  strangulated  hernia,  varico- 
cele, minor  amputations,  exploratory  operations,  etc.  Within  the  last 
few  years  the  scope  of  nitrous  oxid  and  oxygen  anesthesia  has  been 
greatly  enlarged,  some  operators  employing  it  in  their  work  to  the 
exclusion  of  ether  in  operations  of  considerable  magnitude  upon 
the  biliary  passages,  kidney,  bladder,  intestines,  and  stomach.  It 
should  be  remembered,  however,  in  connection  with  some  of  the  above 
abdominal  cases,  that  often  complete  relaxation  is  not  obtained  under 
this  form  of  anesthesia. 

Nitrous  oxid  is  contraindicated  in  cases  of  dilated  heart  or  advanced 
valvular  disease,  and  in  patients  with  atheroma  of  the  blood-vessels, 
on  account  of  the  danger  of  cerebral  hemorrhage.  In  children,  the 
mask  and  formidable  appearing  apparatus  frequently  cause  so  much 
fear  as  to  preclude  its  use.  It  is  not  a  suitable  anesthetic  to  employ 
in  patients  with  narrow  or  abnormal  air  passages,  or  in  those  suffering 
from  goiter,  enlarged  tonsils,  or  adenoids.  In  operations  about  the 
rectum  and  perineum,  it  is  sometimes  unsatisfactory,  as  the  patient 
may  stiffen  up  or  straighten  out  the  limbs,  thus  interfering  with  the 
operator.  The  same  may  be  said  of  its  use  in  alcoholics,  or  strong, 
robust,  or  fat  individuals,  though,  according  to  Gwathmey,  by  pre- 
liminary medication  with  morphin  alone,  or  with  morphin  and  chlo- 
retone,  or  morphin  and  hyoscin,  any  patient  can  be  anesthetized 
satisfactorily. 

Apparatus. — Nitrous  oxid  may  be  administered  alone  or  with  air 
by  means  of  any  of  the  usual  inhalers  for  that  purpose,  such  as  Hew- 
itt's, Gwathmey's,  Bennett's  (Fig.  i8),  etc.  In  general,  these  consist 
of  a  metal  mask  with  a  pneumatic  rubber  rim  that  fits  the  face 
accurately  so  as  to  exclude  air,  a  gas  chamber  with  inspiratory  and 
expiratory  valves  or  openings,  and,  attached  to  the  gas  chamber, 
a  rubber  balloon  connected  by  rubber  tubing  with  the  nitrous  oxid 
cylinder.  With  such  apparatus,  air  may  be  admitted  through  the 
openings  provided  for  that  purpose  or  the  inhaler  may  be  removed 
every  two  to  five  inspirations,  allowing  the  patient  to  get  a  supply  of 
pure  air.  Oxygen  may  likewise  be  administered  by  passing  the 
oxygen  tube  under  the  rim  of  the  mask. 


NITROUS    OXID    ANESTHESIA 


25 


When  a  definite  amount  of  oxygen  is  to  be  given,  a  special  appara- 
tus, as  that  of  Hewitt  (Fig.  19),  Gwathmey  (Fig.  20),  Teter,  Cunning- 
ham, or  Gatch,  is  essential.  With  these  inhalers  any  desu"ed  com- 
bination of  nitrous  oxid  gas  and  oxygen  may  be  obtained  by  regulating 
special  s^^'itches,  which  are  provided  with  indicators  showing  the 


Fig,   18. — The  Bennett  nitrous  oxid  gas  inhaler. 


Fig.   19. — The  Hewitt  nitrous  oxid  gas  and  oxygen  inhaler. 

exact  strength  of  the  vapor  which  the  patient  receives.  Carbon 
dioxid,  which  has  been  proved  so  valuable  as  a  respiratory  stimulant, 
is  provided  by  rebreathing  or  by  connecting  the  apparatus  with  a 
tank  of  CO9. 


26 


THE   ADMINISTRATION    OF    GENERAL   ANESTHETICS 


As  with  all  inhalers,  the  metal  parts  should  be  boiled  and  the  rub- 
bers sterilized  in  a  solution  of  i  to  20  carboKc  acid  after  use.  Before 
using,  the  apparatus  should  always  be  tested  to  see  that  it  works 
properly. 

Administration. — In  giving  pure  nitrous  oxid,  the  apparatus  is 
properly  connected  with  the  supply  cylinder,  and  the  rubber  balloon 
is  about  three-fourths  filled  with  gas.  The  gas  should  be  turned  on 
slowly,  as,  at  times,  when  suddenly  released,  it  escapes  from  the  cylin- 
der with  a  loud  noise  which  might  tend  to  frighten  a  nervous  patient. 
The  face-piece  is  then  tightly  appUed  over  the  mouth  and  nose,  so 
that  air  cannot  be  drawn  in  around  the  rubber  rim.     The  expiratory 


Fig.  20. — Gwathmey's  nitrous  oxid  gas  and  oxygen  inhaler. 


valve  is  opened  and  the  patient  is  told  to  breathe  regularly.  After 
two  or  three  breaths  of  air,  during  which  the  patient  becomes  accus- 
tomed to  the  apparatus,  the  gas  is  allowed  to  enter  the  mask  by  open- 
ing the  proper  stopcock.  The  patient  thus  breathes  in  pure  nitrous 
oxid  and  expires  nitrous  oxid  and  air,  so  that  he  constantly  receives 
more  nitrous  oxid  into  the  lungs.  After  a  few  breaths,  the  expiratory 
valve  is  closed  and  the  patient  breathes  the  gas  back  and  forth. 

The  first  few  inspirations  of  pure  gas  are  soon  followed  by  a  change 
in  the  color  of  the  face — it  becomes  dusky,  and  finally  a  deep  Uvid 
hue.     There  is  at  first  incoherent  speech,  but  this  is  soon  followed  by 


NITROUS    OXID    ANESTHESIA 


27 


the  anesthetic  snoring,  rapid  respiration,  and  a  laryngeal  stertor. 
There  is  usually  tremor  or  twitching  of  the  superficial  muscles  of  the 
eyes,  mouth,  neck,  etc.,  and  at  times  complete  rigidity  and  violent 
jactitations  of  the  limbs.  The  anesthetic  cannot  be  continued 
beyond  this  point  without  danger  of  asphyxiation.  If  the  mask  is 
removed,  there  is  still  a  period  of  surgical  anesthesia,  lasting  about  a 
minute.  This  is  soon  followed  by  a  reactionary  redness  or  blush 
about  the  face,  and  a  return  to  normal  breathing.  By  reapplying  the 
mask  before  the  patient  comes  entirely  out,  and  administering  more 
nitrous  oxid,  the  anesthesia  may  be  prolonged  nearly  an  hour,  pro- 


FiG.  21. — Showing  the  method  of  administering  nitrous  oxid  gas. 

vided  sufficient  air  is  admitted  to  avoid  extreme  cyanosis,  stertor, 
and  muscular  twitchings,  and  yet  not  so  much  as  to  keep  the  patient 
insufficiently  anesthetized.  This  may  be  accomplished  by  allowing 
two  to  five  breaths  of  nitrous  oxid  to  one  of  air,  or  the  air  may  be 
administered  in  combination  with  the  nitrous  oxid  through  the  open- 
ing provided  on  the  inhaler  for  that  purpose.  A  slight  duskiness  of 
the  countenance,  moderate  snoring,  and  regular  respiration  should  be 
aimed  at. 

Administered  with  oxygen,  a  complete  absence  of  symptoms  of 
asphyxia  is  secured.  An  even  anesthesia  is  best  obtained  with  some 
form  of  apparatus  that  accurately  regulates  the  percentage  of  oxygen. 
The  technic  is  essentially  the  same  as  that  employed  in  giving  pure 


28  THE    ADMINISTRATION   OF   GENERAL   ANESTHETICS 

nitrous  oxid.  The  patient  first  breathes  pure  air,  then  the  nitrous  oxid 
is  turned  on,  and  finally  the  oxygen.  Starting  with  but  a  very  small 
proportion  of  oxygen  (2  to  3  per  cent.)  it  may  be  increased  to  from  5 
to  10  per  cent.,  or  more,  depending  upon  the  case.  Enough  oxygen 
should  always  be  given  to  prevent  cyanosis  without  detracting  from 
the  anesthetic  effects  of  the  nitrous  oxid.  There  is  no  doubt  that  it 
requires  special  training  for  one  to  become  expert  in  administering 
this  combination.  Success  depends  upon  the  abihty  of  the  anesthe- 
tist to  provide  a  combination  of  gas  and  oxygen  that  will  produce 
narcosis  without  cyanosis.  With  the  proper  amount  of  oxygen,  the 
patient  goes  under  the  anesthetic  in  two  to  three  minutes  without 
any  of  those  unpleasant  symptoms  seen  with  pure  nitrous  oxid,  the 
color  of  the  skin  is  normal,  the  breathing  becomes  regular  and  slightly 
snoring,  and  the  pulse  may  be  slightly  increased  in  rate.  Recovery  is 
rapid  and  is  usually  unaccompanied  by  any  unpleasant  after-effects. 

NITROUS  OXID  AND  ETHER  SEQUENCE 

By  this  method  the  patient  is  thoroughly  anesthetized  with  gas 
and  then  a  change  is  slowly  made  to  ether.  It  is  a  most  valuable 
method  for  avoiding  the  disagreeable  effects  of  the  early  stages  of 
anesthesia  ordinarily  encountered  when  straight  ether  is  admin- 
istered from  the  start.  A  combination  of  gas  and  ether  carries  the 
patient  into  a  stage  of  surgical  anesthesia  very  rapidly — usually  in 
about  one  to  three  minutes.  Much  less  ether  is  required  both  in 
starting  and  maintaining  narcosis  than  when  ether  alone  is  employed, 
and,  the  patient  not  being  saturated  with  the  drug,  the  after-effects 
of  ether  anesthesia  are  not  nearly  so  frequent  or  pronounced.  It  is 
safer  than  ether  given  alone  by  the  open  or  semiopen  inhalers,  prob- 
ably because  the  stage  of  excitement  is  absent,  and,  in  the  second 
place,  the  carbon  dioxid  content  is  maintained  and  the  ether  vapor 
is  warmed  through  the  constant  rebreathing;  and,  finally,  a  much 
smaller  amount  of  the  anesthetic  is  required. 

Apparatus. — If  desired,  the  gas  may  be  administered  by  any  of  the 
ordinary  nitrous  oxid  gas  inhalers,  and  the  ether  by  the  open  or  semi- 
open  method,  though  a  combination  gas  and  ether  apparatus,  such  as 
Clover's,  Hewitt's,  Bennett's  (Fig.  22),  Gwathmey's  (Fig.  23),  or 
Pedersen's,  is  preferable  and  more  convenient.  These  inhalers  con- 
sist of  the  usual  metal  mouth-piece  and  inflatable  rubber  rim,  inspira- 
tory and  expiratory  valves,  and  gas  bag.  In  addition,  the  inhalers 
have  an  ether  chamber  containing  gauze  upon  which  the  ether  is 


NITROUS    OXID    AND    ETHER    SEQUENCE  29 

poured.  They  are  arranged  so  that  gas  is  first  administered  in  the 
usual  way,  and  then  by  slowly  revolving  a  drum  the  ether  chamber  is 
gradually  opened,  the  quantity  of  gas  at  the  same  time  being  corre- 
spondingly diminished,  until  finally  the  patient  receives  full  strength 


Fig.   22. — The  Bennett  gas  and  ether  apparatus. 

ether  vapor.  In  the  Bennett  apparatus  the  gas  bag  is  removed  as 
soon  as  the  patient  is  well  under  the  nitrous  oxid,  and  a  second  bag  is 
substituted;  with  the  Gwathmey  inhaler,  this  is  improved  upon,  and 


Fig.  23. — Gwathmey's  gas  and  ether  apparatus. 

but  one  bag  is  used  for  both  gas  and  ether.  As  with  all  apparatus 
having  mechanism  likely  to  get  out  of  order,  the  inhalers  should 
always  be  tested  before  using.  The  same  inhaler  should  never  be 
taken  from  one  person  to  another  without  sterilization. 


30  THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS 

Administration. — The  apparatus  is  properly  connected  and  the 
gauze  in  the  ether  chamber  is  well  saturated  with  ether.  The  mask  is 
applied  to  the  face  so  that  it  fits  snugly,  and  the  patient  is  instructed 
to  breathe  naturally.  As  soon  as  it  is  seen  that  the  patient  is  breath- 
ing properly,  the  expiratory  valve  is  opened  and  the  nitrous  oxid  is 
turned  on.  After  a  few  breaths  the  expiratory  valve  is  closed  and  the 
patient  breathes  the  gas  back  and  forth,  gradually  going  under  its 
influence,  which  is  denoted  by  duskiness  of  color,  irregular  snoring 
respiration,  and  muscular  twitching. 

The  addition  of  ether  vapor  is  now  commenced  by  rotating  the 
ether  chamber  slowly.  A  small  amount  of  ether  is  administered  at 
first,  and  this  is  gradually  increased  until  the  patient  is  getting  the  full 
strength  of  ether.  During  this  period,  if  symptoms  of  asphyxia 
from  the  gas  appear,  small  quantities  of  air  should  be  admitted  from 
time  to  time  through  the  air  valve,  but  not  in  such  amount  as  to  allow 
the  patient  to  come  out.  As  soon  as  anesthesia  is  well  established, 
which  usually  takes  less  than  two  minutes,  the  gas  is  discontinued  and 
the  administration  of  the  ether  is  proceeded  with  in  the  usual  way 
when  using  a  closed  cone. 

In  giving  a  combination  of  gas  and  ether,  care  must  be  taken  to 
turn  on  the  ether  rather  slowly  at  first.  If  the  patient  commences  to 
cough  and  hold  his  breath,  the  ether  should  be  turned  on  less  rapidly, 
or  entirely  stopped,  until  regular  breathing  is  again  established. 
When  administered  properly,  the  patient  goes  under  the  anesthetic 
with  surprising  quickness,  without  any  discomfort  or  struggling,  and, 
after  anesthesia  is  once  estabhshed,  but  little  anesthetic  is  required 
to  maintain  it.  Some  duskiness  of  countenance  and  cyanosis  are  to 
be  expected  from  the  nitrous  oxid,  and  the  constant  rebreathing  of  the 
same  vapor,  but  this  may  be  controlled  by  a  careful  regulation  of  the 
air  valves. 

ETHYL  CHLORID  ANESTHESIA 

Ethyl  chlorid  is  a  colorless,  very  volatile  and  inflammable  liquid. 
If  pure,  it  has  an  ethereal  odor,  and  should  not  be  acid  to  litmus. 
For  general  anesthetic  purposes  the  purest  quality  of  the  drug  should 
be  used,  and  only  that  labelled  "for  general  anesthesia."  This  can  be 
obtained  in  containers  furnished  with  a  spring  stopcock,  which  per- 
mits the  drug  to  be  administered  in  a  fine  stream  in  any  desired  quan- 
tity (Fig.  24),  or  in  hermetically  sealed  glass  tubes  containing  about 
I  1/4  drams  (5  c.c.)  of  the  drug.  The  latter  is  best  suited  for  the 
closed  inhalers,  the  whole  amount  being  emptied  into  the  inhaler  at 


ETHYL    CHLORID    ANESTHESIA 


31 


once.     Ethyl  chlorid  Is  decomposed  by  light  and  air,  hence  it  should 
be  kept  in  a  dark  place  and  in  tightly  stoppered  tubes. 

When  inhaled,  it  is  very  rapidly  absorbed  and  is  quickly  eHmi- 
nated,  anesthesia  being  produced  in  from  thirty  seconds  to  a  minute  or 
so,  and  lasting  two  to  three  minutes  after  the  withdrawal  of  the  anes- 
thetic. Recovery  is  not  quite  so  rapid  as  with  nitrous  oxid,  and  after- 
effects, such  as  headache,  nausea,  vomiting,  and  dizziness,  are  not  at 
all  uncommon.  It  is  not  nearly  so  safe  as  nitrous  oxid,  nor  so  pleas- 
ant an  anesthetic  to  take.  It  has  the  advantage,  however,  of  not 
producing  cyanosis,  and  the  anesthetic  effects  are  more  prolonged; 


Fig.  24. — Ethyl  chlorid  tube. 

fiu-thermore,  it  may  be  administered  without  special  apparatus.  It 
stimulates  both  the  heart  and  respiration,  increasing  the  rate  and  the 
depth  of  the  latter,  but  it  lowers  blood-pressure  through  dilatation  of 
the  peripheral  vessels. 

Suitable  Cases. — Ethyl  chlorid  is  employed  mainly  for  brief 
operations  or  for  examinations  not  requiring  full  muscular  relaxation, 
and  as  a  preliminary  to  ether  to  get  the  patient  under  rapidly  without 
strugghng  and  excitement.     It  acts  especially  well  in  children  on 


Fig.  25. — Showing  the  Schimnaelbusch  mask  covered  with  gauze  and  oil  silk  for  the 
administration  of  ethyl  chlorid. 


account  of  its  rapidity  of  action.  It  should  never  be  immedi- 
ately followed  by  chloroform,  as  both  are  circulatory  depressants. 
Its  use  is  contraindicated  when  there  is  any  respiratory  obstruction. 
Apparatus. — Omng  to  its  great  volatility,  ethyl  chlorid  is  most 
satisfactorily  administered  by  means  of  a  closed  inhaler,  though  the 
semiopen  method  may  be  employed,  and  is  preferred  by  many  as 
being  safer.     For  the  latter,  one  may  employ  an  Esmarch  or  Schim- 


32 


THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 


melbusch  mask,  over  the  gauze  of  which  is  placed  some  impervious 
material,  as  oil  silk  or  rubber  tissue,  with  a  small  opening  through 
which  the  drug  is  sprayed  (Fig.  25);  or  an  Allis  inhaler  may  be  used, 
leaving  a  small  opening  in  the  top.  Any  of  the  ordinary  closed  inhal- 
ers may  be  utilized  for  administering  ethyl  chlorid  by  simply  spraying 
the  drug  into  the  ether  bag. 

There  are  a  number  of  inhalers,  however,  devised  especially  for 
this  drug  and  similar  anesthetics.  Ware's  inhaler  (Fig.  26)  consists 
of  a  pliable  rubber  mouth-piece,  to  the  top  of  which  is  fitted  a  metal 
chimney.  At  the  point  the  latter  joins  the  mouth-piece,  several 
layers  of  gauze  are  interposed  upon  which  the  anesthetic  is  sprayed 

through  the  top  of  the  apparatus.  The 
somnoform  inhaler  consists  of  a  glass  face- 
piece  with  an  inflatable  rubber  rim  and 
rubber  balloon.  The  balloon  is  attached 
to  the  mouth-piece  by  a  T-shaped  cham- 
ber which  is  provided  with  a  valve  and  a 
small  opening  through  which  the  anes- 
thetic may  be  sprayed. 

Administration. — In  administering 
ethyl  chlorid  by  the  closed  method,  the 
inhaler  is  placed  over  the  patient's  face 
during  expiration  in  order  to  fill  the  bag, 
and,  as  soon  as  the  patient  is  breathing 
regularly,  from  i  to  i  1/4  dr.  (4  to  5  c.c.) 
of  ethyl  chlorid  are  sprayed  into  the  bag, 
or,  if  a  special  inhaler  is  used,  into  the  opening  provided  for  the 
purpose.  If  the  face-piece  be  tightly  applied,  so  as  to  prevent  the 
entrance  of  air,  signs  of  anesthesia  appear  in  from  thirty  seconds  to 
one  minute.  As  soon  as  anesthesia  is  produced,  the  patient  should 
be  allowed  to  have  air. 

Full  anesthesia  is  characterized  by  rapid  and  shghtly  stertorous 
breathing,  dilated  pupils,  absence  of  conjunctival  reflex,  and  more 
or  less  complete  relaxation.  There  is  no  cyanosis,  though  the  color 
of  the  skin  is  heightened  from  the  dilatation  of  the  peripheral  vessels. 
The  inhaler  should  now  be  removed  and  the  operation  proceeded  with, 
or  else  ether  is  substituted.  If  the  patient  recover  too  rapidly,  more 
anesthetic  may  be  given,  provided  a  plentiful  supply  of  air  is  allowed. 
By  an  interrupted  administration  of  ethyl  chlorid — that  is,  first 
securing  deep  narcosis  and  then  giving  air — a  prolonged  light  anes- 
thesia may  be  obtained,  though  at  times  muscular  relaxation  is  not 


Fig.  26. — Ware's  ethyl 
chlorid  inhaler. 


ANESTHETIC   MIXTURES  33 

complete  and  the  patient  is  apt  to  remain  partly  conscious.  Danger 
signs  from  ethyl  chlorid  anesthesia  are  gasping,  shallow  respirations, 
pupils  widely  dilated  and  not  reacting  to  light,  and  general  pallor  of 
the  skin. 

Administered  by  the  semiopen  method,  a  greater  quantity  of  the 
drug  will  be  necessary,  and  somewhat  more  time  will  be  consumed  in 
getting  the  patient  under  than  by  the  closed  method.  The  mask  is 
placed  over  the  face,  air  being  excluded  as  far  as  possible  by  surround- 
ing it  with  a  towel,  and  the  drug  is  simply  sprayed  upon  the  inhaler 
in  a  steady  stream  until  anesthesia  is  produced. 

ANESTHETIC  MIXTURES 

The  addition  of  ether,  alcohol,  and  other  drugs  to  chloroform  has 
been  extensively  practised  for  the  purpose  of  modifying  the  action  and 
avoiding  the  dangers  of  the  latter.  There  are  a  large  number  of  such 
mixtures,  varying  both  in  composition  and  in  the  relative  proportion 
of  their  separate  constituents.     The  A.  C.  E.  mixture  is  composed  of: 

Alcohol,  I  part 

Chloroform,  2  parts 

Ether,  3  parts 

A  mixture  somewhat  similar  to  this,  known  as  the  Billroth  mixture, 
contains: 

Alcohol,  I  part 

Ether,  i  part 

Chloroform,  3  parts 

The  C.  E.  or  Vienna  mixture  contains: 

Chloroform,  i  part 

Ether,  3  parts 

Schleich's  mixture  for  general  anesthesia  is  composed  of  ether,  chloro- 
form, and  petroleum  ether.  This  is  furnished  in  three  strengths  of 
solution,  one  for  light  narcosis,  one  for  moderate  narcosis,  and  one  for 
deep  narcosis. 

Anesthol  is  composed  of: 

Ethyl  chlorid,  17        per  cent. 

Chloroform,  35.89  per  cent. 

Ether,  47  ■  10  per  cent. 

Of  these,  the  A.  C.  E.  mixture,  the  C.  E.  mixture,  and  anesthol 
are  most  used  in  this  country. 

3 


34  THE    ADMINISTRATION    OF    GENEIL\L    ANESTHETICS 

In  point  of  safety,  mixtures  occupy  a  place  between  chloroform 
and  ether,  the  added  safety  over  chloroform  depending  mainly 
upon  the  stimulating  effect  of  the  ether.  The  comphcations  and 
dangers  that  may  arise  during  the  administration  of  these  mixtures, 
however,  are  those  met  with  from  chloroform  rather  than  from  ether, 
and,  as  a  general  principle,  mixtures  should  be  given  with  as  much 
caution  as  would  be  observed  in  the  administration  of  the  most  dan- 
gerous drug  they  contain. 

Suitable  Cases. — When  nitrous  oxid  or  ether  are  considered  inad- 
visable, a  mixture  of  chloroform  and  ether  is  the  next  choice.  Thus 
in  children  and  in  persons  over  sixty,  in  the  fat  and  plethoric,  in  cases 
suffering  from  chronic  lung  trouble,  as  emphysema,  bronchitis,  etc., 
in  advanced  cardiac  disease  with  lack  of  compensation,  in  atheroma, 
in  alcoholics,  in  those  with  renal  disease,  and  in  cerebral  operations 
mixtures  are  most  useful.  Being  agreeable  to  take,  they  are  often 
used  as  a  means  of  obtaining  primary  anesthesia  to  ether  when  nitrous 
oxid  or  ethyl  chlorid  are  unavailable. 

Apparatus. — Mixtures  containing  chloroform  should,  always  be 
given  by  the  open  method,  and  for  this  purpose  some  such  mask  as 
the  Esmarch  or  Schimmelbusch,  previously  described  (see  page  lo), 
should  be  used. 

Administration. — The  same  general  rules  and  principles  that 
govern  the  administration  of  chloroform  should  be  followed  in  the  use 
of  mixtures.  They  should  always  be  given  with  the  patient  in  a 
recumbent  position.  The  inhalation  is  begun  gradually  with  the 
admixture  of  plenty  of  air.  Small  quantities  of  the  anesthetic  fre- 
quently repeated  are  to  be  used  in  preference  to  a  few  large  doses. 

The  anesthesia  produced  by  mixtures  is  only  a  slight  modification 
of  chloroform  narcosis.  On  account  of  the  stimulating  effect  of  the 
ether,  the  pulse  is  fuller  and  more  rapid,  respirations  are  deeper,  and 
the  whole  appearance  of  the  patient  is  better  than  when  chloroform 
alone  is  used.  Dangerous  signs,  should  they  appear,  are  not  quite 
so  abrupt  as  with  chloroform  and  may  usually  be  detected  before  a 
serious  or  hopeless  condition  supervenes. 

SPECIAL  METHODS  OF  ANESTHESIA 

Intubation  Anesthesia. — In  operations  about  the  mouth,  such 
as  is  required,  for  instance,  in  removal  of  the  tongue,  repair  of  a  cleft 
palate,  resection  of  the  jaw,  etc.,  the  administration  of  the  anesthetic 
by  means  of  tubes  passed  into  the  pharynx  through  the  nose,  known 


SPECIAL   METHODS    OF    ANESTHESIA 


35 


as  Crile's  method,  will  be  found  of  great  service.  The  advantages  are 
that  the  anesthetist  and  inhaler  are  removed  from  the  seat  of  opera- 
tion so  that  they  in  no  way  interfere  with  the  operator,  and  the  anes- 
thetic may  be  administered  continuously,  as  it  is  not  necessary  to 
delay  or  stop  the  operation  every  little  while  in  order  to  get  the  patient 
well  under,  as  is  the  case  when  the  ordinary  interrupted  form  of  anes- 
thesia is  employed.  As  the  pharynx  is  packed  with  gauze,  aspiration 
of  mucus  or  blood  from  the  site  of  operation  is  avoided,  nor  is  there 
vomiting  or  coughing  up  of  blood  that  may  have  collected  in  the  back 
of  the  pharynx. 

Apparatus. — The  apparatus  consists  of  two  rubber  tubes  of  a  size 
that  will  comfortably  pass  through  the  nares,  each  about  8  inches 


Fig.  27. — Showing  the  method  of  inserting  the  tubes  and  packing  the  pharynx  for 

intubation  anesthesia. 


(20  cm.)  long,  preferably  cut  at  their  distal  ends  at  an  acute  angle,  and 
furnished  with  side  openings.  The  upper  ends  of  the  tubes  are 
connected  to  the  two  arms  of  a  Y-shaped  glass  tube,  to  the  long  arm 
of  which  is  attached  by  means  of  a  third  piece  of  rubber  tubing  a  fun- 
nel lightly  packed  with  gauze. 

Technic. — After  full  anesthesia  has  been  obtained  in  the  usual 
way,  a  mouth  gag  is  inserted,  the  throat  is  well  cleared  of  mucus  by 
means  of  small  gauze  swabs,  and  the  two  tubes,  well  lubricated,  are 
carefully  passed  through  the  nares  and  down  to  the  epiglottis  with 
their  pointed  ends  directed  downward  and  forward.     The  tongue  is 


36  THE   ADMINISTRATION   OF   GENERAL  ANESTHETICS 

then  drawn  well  forward  and  the  whole  pharynx  is  firmly  packed  with 
a  single  piece  of  gauze  in  such  a  way  that  the  packing  does  not  ob- 
struct the  lateral  fenestras  or  ends  of  the  tubes  (Fig.  27).  Care 
should  be  taken  at  this  stage  to  hsten  at  the  ends  of  the  tubes  in  order 
to  make  sure  that  the  patient  is  breathing  properly.  If  he  is  not, 
the  gauze  should  be  promptly  removed  and  the  pharynx  repacked. 
As  soon  as  regular  breathing  is  established  through  the  tubes,  the 
funnel  is  connected  and  the  anesthetic  is  continued  by  the  drop 
method. 

Intratracheal  Insufflation  Anesthesia. — Intratracheal  in- 
sufHation  anesthesia,  tirst  suggested  by  Meltzer  and  Auer,  con- 
sists essentially  in  the  introduction  deep  into  the  trachea  of  a 
flexible  tube  with  a  diameter  considerably  less  than  the  lumen 
of  the  trachea  and  the  forcing  of  a  current  of  air  and  ether  vapor 
through  the  tube,  the  space  between  the  tube  and  trachea  per- 
mitting the  return  of  air  from  the  lungs.  This  method  of  anes- 
thesia was  originally  adopted  to  supply  a  positive  pulmonary  pres- 
sure for  operations  upon  the  thoracic  viscera,  the  resistance  to  the 
return  of  air  through  the  trachea  being  sufficient  to  prevent  the 
lungs  from  collapsing  when  the  thorax  is  opened.  For  this  pur- 
pose it  has  largely  replaced  the  various  differential  pressure 
chambers. 

Intratracheal  insufflation  is,  furthermore,  of  special  value  in  opera- 
tions about  the  mouth,  tongue,  throat,  jaws,  and  nose  as  the  continu- 
ous reflux  air  current  prevents  the  aspiration  of  blood,  mucus,  vom- 
itus,  or  other  foreign  matter  from  the  pharynx  into  the  trachea.  It 
is  also  indicated  in  cases  where  normal  respiration  is  interfered  with, 
and  in  operations  about  the  neck,  head,  or  face  it  permits  the  operator 
to  work  in  an  unobstructed  field.  The  easy,  even  anesthesia  pro- 
duced by  this  method,  the  marked  absence  of  shock  and  post- 
operative vomiting  attending  its  use,  and  the  fact  that  the  dosage 
may  be  accurately  regulated  has  led  some  surgeons  to  employ  it  as  a 
routine  in  preference  to  the  ordinary  inhalation  methods. 

WTiile  some  accidents  have  attended  the  use  of  insufflation 
anesthesia,  they  have  been  due  to  faulty  technic.  If  an  approved 
form  of  apparatus  is  used  and  certain  cautions  are  observed,  there  is 
no  danger.  The  apparatus  should  alwa}-s  be  provided  with  a  safety 
valve  to  guard  against  overpressure  and  there  must  be  no  chance  of 
Hquid  ether  entering  the  tracheal  tube.  Furthermore,  before  begin- 
ning the  insufflation,  the  operator  must  assure  himself  that  the  tube 
is  in  the  trachea  and  not  in  the  esophagus,  that  the  tube  is  not  intro- 


SPECIAL    METHODS    OF    ANESTHESIA 


37 


duced  beyond  the  bifurcation  of  the  trachea,  and  that  during  the 
insertion  of  the  tube  the  pharynx  and  trachea  are  not  injured. 

Apparatus. — There  are  several  good  intratracheal  insufflation 
machines  on  the  market,  such  as  Elsberg's,  Janeway's,  and  Boothby's, 
which  are  elaborate  in  their  completeness.  A  very  simple  and  inex- 
pensive apparatus  (Fig.  28),  which  answers  all  purposes,  is  described 
by  Meltzer  (Keen's  Surgery,  Vol.  VI)  as  follows: 

"By  means  of  a  glass-blower's  foot-bellows  (B)  air  is  driven 
through  a  system  of  branching  tubes  into  the  intratracheal  tube 
In.-T) .     The  first  branching  of  the  tubes  is  introduced  for  the  purpose 


Fig.  28. — Apparatus  for  intratracheal  insufflation  anesthesia   (Meltzer  in  Keen's 

Surgery) . 


of  regulating  the  interruption  of  the  air-stream.  From  the  right 
branch  a  tube  is  led  off  laterally,  carrying  a  stopcock  (St.  3),  which  is  to 
be  used  for  the  interruptions  of  the  air-current.  During  the  opening 
of  the  stopcock  a  part  of  the  air-current  continues  through  the  left 
tube,  thus  preventing  too  great  a  reduction  of  the  pressure,  which  is 
undesirable.  By  means  of  a  screw-clamp  (S.C.)  the  amount  of  air 
which  is  to  pass  through  the  left  tube  can  be  regulated;  a  narrowing 
of  this  tube  causes  a  greater  collapse  of  the  lung  during  the  interrup- 
tion. The  second  branching  of  the  tubes  is  introduced  for  the  pur- 
pose of  regulating  the  anesthesia.  The  ether  bottle  (E)  is  interpo- 
lated in  the  left  branch;  the  right  branch  runs  uninterrupted  outside 
of  the  bottle  to  unite  with  the  part  of  the  left  tube  which  comes  from 
the  ether  bottle.     When  the  stopcock  in  the  right  branch  (St.  2)  is 


38 


THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 


closed,  all  the  air  passes  through  the  ether  bottle;  when,  instead,  both 
stopcocks  in  the  left  branch  (St.  i  and  St.  4)  are  closed,  only  pure  air 
reaches  the  intratracheal  tube,  and  when  all  three  stopcocks  are 
open  only  one-half  of  the  air  is  saturated  with  the  anesthetic.  By 
partial  closing  of  the  stopcocks  various  degrees  of  anesthesia  can  be 
obtained.  The  third  opening  in  the  ether  bottle  carries  a  tube  with 
a  funnel  (F)  through  which  the  bottle  is  filled  with  the  anesthetic; 
the  tube  is  otherwise  kept  tightly  closed  by  means  of  a  screw-clamp 
(S.C.).  All  three  rubber  stoppers  are  firmly  and  permanently  wired 
down  to  resist  various  pressures.  When  the  ether  bottle  is  to  be 
refilled  during  insufflation,  both  stopcocks  on  the  left  side  are  closed, 
while  the  one  on  the  right  side  is  open." 

"The  tube  which  connects  the  anesthesia  circle  of  tubing  with  the 
intratracheal  tube  (In.-T)  carries  two  lateral  tubes;  one  is  connected 
with  a  manometer  (M),  which  needs  no  description,  and  the  other 
leads  to  a  safety  valve  (S.V.)  of  a  simple  construction.     To  the  rubber 


Fig.   29. — Jackson's  direct  view  laryngoscope. 

tubing  is  attached  a  graduated  glass  tube,  the  lower  end  of  which  is 
immersed  under  the  surface  of  the  mercury  in  this  bottle  to  a  depth 
corresponding  to  the  pressure  which  is  desired  for  the  intratracheal 
insuffiation.  For  instance,  if  the  pressure  should  be  not  more  than 
20  mm.  of  mercury,  the  glass  tube  is  immersed  just  20  mm.  below  the 
surface  of  the  mercury.  The  glass  tube  is  kept  in  the  desired  place 
by  means  of  a  rubber  ring  resting  upon  the  opening  of  the  mercury 
bottle.  This  device  gives  great  safety  to  the  working  of  the  method. 
No  matter  how  strong  and  irregular  the  bellows  is  worked,  the  intra- 
tracheal pressure  could  never  rise  above  the  one  arranged  for;  the 
surplus  of  air  escapes  through  the  tube  from  under  the  mercury." 
The  tracheal  tube  should  be  flexible  and  elastic,  about  14  inches 


SPECL\L    METHODS    OF    AXESTHESLA.  39 

(35  cm.)  long,  with  a  mark  lo  1/2  inches  (27  cm.)  from  the  distal  end 
and  with  the  opening  preferably  at  the  end.  A  silk  woven  catheter, 
No.  22  to  24  French,  and  for  children  of  a  correspondingly  small  size, 
is  frequently  used.  There  will  be  required  in  addition  a  mouth-gag 
and  a  Jackson's  direct  view  laryngoscope  (Fig.  29).  Elsberg  has 
devised  a  special  bit  or  holder  to  keep  the  tube  from  sHpping  up  or 
down  after  it  has  been  properly  introduced,  but,  in  its  absence, 
adhesive  plaster  may  be  employed  for  this  purpose. 

Asepsis. — The  tracheal  tube  and  the  laryngoscope  must  be  sterile. 

Preparations  of  the  Patient. — The  patient  is  prepared  as  for  any 
anesthesia  (see  page  2)  and  is  given  morphin  gr.  1/6  (0.0108  gm.) 
and  atropin  gr.  i/ioo  fo. 00065  S^^-)  by  hypodermic  half  an  hour 
before  the  operation. 

Technic. — The  patient  is  first  etherized  in  the  usual  way  and  is 
placed  upon  the  operating-table  with  his  head  hanging  over  the  edge 
in  which  position  it  is  supported  by  an  assistant  (see  Fig.  474), 
the  patient's  mouth  being  held  open  by  a  mouth-gag.  ^  The 
Jackson  laryngoscope  is  then  introduced  (for  the  technic  of  this  see 
page  398),  and,  with  the  epiglottis  pulled  forward  by  the  beak  of  the 
instrument  so  that  a  good  view  of  the  larynx  is  obtained,  the  tracheal 
catheter,  wet  in  cold  water,  is  inserted. .  No  force  should  be  employed 
in  introducing  the  catheter,  and,  as  soon  as  it  is  well  in  the  larynx, 
the  tubular  speculum  is  removed.  The  catheter  is  then  pushed  for- 
ward until  it  meets  a  resistance  which  is  generally  the  right  bronchus. 
The  catheter  is  then  withdrawn  2  to  2  1/2  inches  (5  to  6  cm.)  until  the 
mark  on  the  catheter  is  at  the  patient's  teeth.  The  operator  must 
be  certain  that  the  catheter  is  in  the  patient's  trachea  and  not  in  the 
esophagus.  The  catheter  is  finally  fixed  in  place,  and,  after  the 
apparatus  is  properly  connected,  the  insufflation  of  the  air  and  ether 
vapor  is  commenced.  The  vapor  at  first  should  be  blown  in  under 
sHght  pressure,  that  is,  about  10  mm.  of  mercury  and  then  under 
higher  pressure — 15  to  20  mm.  of  mercury.  The  air  current  should  be 
interrupted  5  to  6  times  a  minute  by  opening  the  vent  for  that  purpose 
a  second  or  two  at  a  time.  The  anesthesia  is  pushed  to  complete 
muscular  relaxation  and  abohtion  of  reflexes,  and,  when  the  desired 
degree  of  narcosis  is  obtained,  the  dose  of  ether  should  be  kept  uni- 
form, as  the  degree  of  anesthesia  from  a  certain  dose  is  practically 
stationary.  At  all  times  it  should  be  seen  that  there  is  a  free  passage 
for  air,  and  the  tongue  should  not  be  allowed  to  fall  back  and  produce 
any  obstruction.  A  spasm  of  the  glottis  may  in  some  cases  be  the 
cause  of  obstruction;  if  so.  full  anesthesia  will  relieve  the  condition. 


40  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

The  color  and  respirations  of  the  patient  should  be  carefully  watched, 
and,  if  the  latter  become  shallow  and  infrequent,  the  anesthetic 
should  be  diminished. 

For  ordinary  cases,  the  manometer  is  kept  at  15  to  20  mm.  of 
mercury.  In  operations  on  the  thoracic  viscera,  the  pressure  will 
depend  upon  the  distention  of  the  lung  desired;  it  should,  however, 
never  be  higher  than  50  mm.  of  mercury.  If  the  catheter  proves  too 
small  to  keep  the  lung  inflated  when  the  thorax  is  opened,  Meltzer 
recommends  that  pressure  be  made  over  the  middle  of  the  thyroid 
cartilage  every  few  moments. 

At  the  completion  of  the  operation,  the  ether  is  discontinued  and 
pure  air  is  insufflated  for  a  moment  or  two  before  the  tube  is  with- 
drawn in  order  to  remove  as  much  of  the  anesthetic  vapor  as  possible 


Fig.  30. — The  Trendelenburg  apparatus  for  tracheal  anesthesia. 

Anesthesia  Through  a  Tracheal  Opening. — In  some  opera- 
tions upon  the  tongue,  larynx,  or  pharynx  it  becomes  necessary  to 
administer  the  anesthetic  through  an  opening  in  the  trachea. 

Apparatus. — For  this  purpose  a  Hahn  or  a  Trendelenburg 
cannula  is  employed.  These  instruments  consist  essentially  of  a 
metal  funnel,  covered  or  filled  with  gauze  upon  which  the  anesthetic 
is  dropped,  and  connected  with  a  special  tracheotomy  tube  by  means 
of  a  piece  of  tubing.  The  tracheal  tube  of  the  Hahn  apparatus  is 
surrounded  by  a  flat  dried  sponge  fastened  securely  in  place,  which, 
when  wet,  swells  up  and  acts  as  a  tampon,  preventing  blood  from  de- 
scending along  the  side  of  the  tube.  The  same  result  is  obtained  with 
the  Trendelenbm-g  instrument  (Fig.  30)  by  surrounding  the  lower 
portion  of  the  cannula  with  a  delicate  air  bag,  which  is  gently  inflated 


SPECIAL   METHODS    OF    ANESTHESIA 


41 


by  compressing  an  inflating  bulb  supplied  with  the  apparatus  as  soon 
as  the  tracheotomy  tube  is  in  place  (Fig.  31). 

Technic. — A  preliminary  tracheotomy  is  first  performed  (see 
page  389).  The  tracheal  tube  is  then  introduced  into  the  opening, 
care  being  taken  to  see  that  the  tamponade  is  effective,  so  as  to  pre- 
vent blood  from  entering  the  trachea.  The  tube  to  convey  the  anes- 
thetic vapor  from  the  funnel  is  then  attached  to  the  tracheal  cannula, 
and  the  anesthetic  is  administered  by  dropping  chloroform  on  the 
gauze  of  the  inhaler. 

Intravenous  General  Anesthesia. — Burkhardt  in  1909  de- 
vised a  method  of  producing  general  narcosis  by  administering 
ether  intravenously  in  a  normal  salt  solution.  Since  then  the 
method  has  been  given  a  trial  by  a  number  of  operators  abroad  and 


Fig.  31. — Showing  the  tracheal  cannula  in  place. 


by  a  few  in  this  country,  but  further  experience  will  be  necessary  be- 
fore its  true  value  can  be  determined.  From  our  present  knowledge 
it  is  not  probable  that  intravenous  etherization  will  ever  supplant 
the  inhalation  method  as  a  routine.  In  certain  operations,  as  those 
about  the  face,  upper  air  passages,  mouth,  tongue,  and  neck, 
the  absence  of  a  mask  near  the  field  of  operation  and  the  even  and 
uninterrupted  anesthesia  that  is  produced  by  this  method  is  of 
undoubted  advantage.  Furthermore,  the  stimulating  effect  of  a 
continuous  saline  infusion  makes  the  method  one  of  special  value  in 
ill-nourished,  debilitated,  or  cachectic  subjects.  On  the  other  hand, 
there  are  the  dangers  of  sepsis,  thrombosis,  embolism,  and  pulmonary 
edema  if  all  the  details  of  the  technic  are  not  carefully  observed. 
When  properly  administered  it  is  claimed  that  the  anesthesia  is 
rapidly  obtained,  that  there  is  seldom  any  stage  of  excitement,  that 


42 


THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 


pulmonary  irritation  and  nausea  are  absent,  and  that  the  recovery 
from  the  anesthesia  is  prompt  and  without  discomfort.  According  to 
Kummell  intravenous  anesthesia  is  contraindicated  in  the  presence  of 
arterio-sclerosis,  myocarditis,  and  general  plethora. 

In  the  early  cases  in  which  this  method  was  employed,  an  inter- 
rupted form  of  anesthesia  was  given,  that  is,  a  quantity  of  ether  solu- 
tion sufficient  to  get  the  patient  under  was  in- 
fused and  the  flow  was  then  stopped,  the  infu- 
sion being  continued  when  the  patient  com- 
menced to  show  signs  of  coming  out.  The 
uneven  anesthesia  this  produced  and  the  fact 
that  some  cases  of  venous  thrombosis  and  pul- 
monary embolism  were  reported  as  a  sequel  led 
to  the  adoption  of  a  continuous  infusion  as  the 
only  safe  method. 

Apparatus. — An  apparatus,  such  as  described 
by  Rood  {British  Medical  Journal,  Oct.  21, 
191 1),  which  will  permit  a  continuous  but  slow 
flow  of  solution  is  required.^  The  apparatus 
should  consist  of  (i)  a  glass  reservoir  with  a  ca- 
pacity of  3  pints  (1500  c.c.)  supported  upon  a 
stand  at  a  height  of  8  feet  (240  cm.)  from  the 
floor,  (2)  a  glass  dripping  chamber  with  a  capa- 
city of  8  ounces  (250  c.c.)  and  (3)  a  warming 
chamber  surrounded  by  a  jacket  containing 
water  at  a  temperature  of  100°  F.  (38°  C.)  (Fig. 
32).  When  the  apparatus  is  working  the  solu- 
tion drips  from  the  pipette  leading  from  the  res- 
ervoir into  the  indicator,  the  lower  half  of  which 
is  filled  with  solution  and  the  upper  half  with  air. 
A  tap  below  the  indicator  controls  the  rate  of 
flow,  the  rate  at  which  the  solution  drips  from 
the  pipette  being  an  index  of  the  rate  at  which 
it  will  enter  the  vein. 

Instruments. — The  operator  will  require  a 
scalpel,  a  pair  of  blunt-pointed  scissors,  thumb  forceps,  an  aneurysm 
needle,  a  needle  holder,  curved  needles  with  a  cutting  edge,  and  No. 
2  plain  catgut  (Fig.  1,2,). 

Solutions. — Ether  is  used  in  a  5  per  cent,  solution  in  normal  salt 

1  In  this  country  an  apparatus  designed  by  Dr.  Honan  is  manufactured  by  the 
Knv  Scheerer  Co.  of  New  York. 


Fig.  32 — Appara- 
tus for  intravenous 
anesthesia. 


SPECIAL   METHODS    OF   ANESTHESIA 


43 


solution  by  Burkhardt  and  in  a  7.5  per  cent,  solution  by  Rood.  Hedo- 
nal  and  paraldehyde  have  also  been  used  with  success.  Fedoroff 
employs  a  0.75  per  cent,  solution  of  hedonal  in  normal  salt  solution. 
The  objection  to  the  use  of  this  drug  is  the  length  of  time  the  hypnotic 
effect  persists  when  large  amounts  are  administered.  Noel  and  Sout- 
tar  {Annals  of  Surgery,  January,  1913)  first  called  attention  to  the 
anesthetic  effects  of  paraldehyde  when  given  intravenously.  Honan 
and  Hassler  {Medical  Record,  Feb.  8,  1913)  employ  paraldehyde 
2  1/2  per  cent,   and  ether  3  per  cent,  in  normal  salt  solution. 

Temperature. — The  solution  should  be  given  at  a  temperature  of 
about  that  of  the  body. 


Fig.  33. — ^Instruments  for  intravenous  anesthesia,  i,  Scalpel;  2,  blunt- 
pointed  scissors;  3,  thumb  forceps;  4,  aneurysm  needle;  5,  needle  holder;  6, 
curved  needles;  7,  No.  2  plain  catgut. 

Quantity. — The  amount  of  solution  used  will  depend  upon  the  age 
and  condition  of  the  patient  and  the  length  of  anesthesia.  Usually 
from  6  to  25  ounces  (200  to  800  c.c.)  of  solution  will  be  required. 

Site  of  Injection. — One  of  the  most  prominent  veins  at  the  bend  of 
the  elbow — preferably  the  median  basilic — is  chosen  for  the  infusion. 

Preparations  of  Patient. — It  is  advisable  to  give  the  patient  hypo- 
dermically  an  hour  before  the  operation  morphin  gr.  1/6  (0.0108  gm.), 
atropin  gr.  i/ioo  (0.00065  gm.),  and  scopolamin  gr.  i/ioo  (0.00065 
gm).  All  clothing  should  be  removed  from  the  arm  chosen  for  the 
infusion  and  the  arm  should  be  bandaged  to  a  well-padded  splint  so 
that  the  infusion  cannula  cannot  be  disturbed  by  movements  of  the 
patient. 


44  THE   ADMINISTRATION    OF    GENERAL   ANESTHETICS 

Asepsis. — The  solution  must  be  absolutely  sterile.  The  instru- 
ments are  sterilized  by  boiling.  The  site  for  the  infusion  is  shaved 
and  thoroughly  cleansed  twenty-four  hours  before  the  operation, 
and  is  then  dressed  with  sterile  gauze.  At  the  time  of  operation 
the  skin  is  painted  with  tincture  of  iodin. 

Technic. — A  tourniquet  is  placed  about  the  arm  above  the  site  of 
injection.  Under  infiltration  anesthesia  with  a  0.2  per  cent,  solution 
of  cocain  or  a  i  per  cent,  novocain  solution  the  median  cephalic  or  the 
median  basilic  vein  is  exposed  through  a  small  incision.  The 
distal  porton  of  the  vein  is  ligated,  the  proximal  portion  is  in- 
cised, and  the  cannula  inserted  with  the  solution  flowing  as  described 
under  intravenous  infusion  (page  138).  The  constriction  is  then 
removed  from  the  arm  and  the  ether  solution  is  allowed  to  run,  at  first 
rapidly  until  anesthesia  is  induced,  and  then  drop  by  drop,  being 
guided  by  the  depth  of  anesthesia. 

It  usually  requires  from  four  to  ten  minutes  to  induce  full  anes- 
thesia, using  3  to  6  ounces  (100  to  200  c.c.)  of  solution.  After 
anesthesia  is  obtained  the  flow  of  solution  should  be  at  about  the 
rate  of  40  to  60  drops  per  minute.  Should  edema  of  the  eyelids 
appear  at  any  time,  the  infusion  should  be  temporarily  stopped. 
During  the  anesthesia  the  anesthetist  must  take  the  same  pre- 
cautions to  maintain  unobstructed  air  passages  as  with  inhalation 
anesthesia. 

At  the  completion  of  the  operation  the  cannula  is  removed,  the 
vein  ligated  with  catgut,  and  the  wound  sutured.  A  sterile  dressing 
is  then  applied. 

Rectal  Anesthesia. — It  consists  in  producing  narcosis  by  means 
of  warm  ether  vapor  slowly  forced  into  the  rectum.  This  method 
was  employed  in  1847  by  Roux.  Later,  in  1884,  it  was  taken  up  by 
Molliere  and  in  this  country  by  Dr.  Weir  and  Dr.  Bull,  but  it  never 
came  into  general  use.  In  the  early  cases  coHcky  pains,  diarrhea, 
bloody  stools,  and  painful  distention  of  the  intestine  were  frequently 
observed.  These  symptoms,  no  doubt,  were  in  many  instances  due 
to  faulty  methods  of  administering  the  anesthetic,  and  with  the 
improved  technic  of  Cunningham  the  method  has  given  better  results. 

Though  it  cannot  be  said  to  be  free  from  risks,  rectal  anesthesia  has 
a  definite  place  among  the  methods  of  anesthetizing  at  our  disposal. 
Its  greatest  field  of  usefulness  is  in  cases  of  extreme  pulmonary  or 
bronchial  involvement  and  empyema,  and  in  operations  about  the 
face,  mouth,  and  larynx,  where  other  means  of  anesthesia  areunsuited. 
To  the  former  class  of  cases  it  is  especially  suited  on  account  of  the 


SPECIAL    METHODS    OF    ANESTHESIA 


45 


absence  of  pulmonary  or  bronchial  irritation  from  the  ether.  While 
it  is  true  that  the  greater  part  of  the  ether  is  eHminated  from  the  lungs,, 
the  direct  irritation  of  concentrated  vapor  is  overcome,  as  is  shown 
by  the  absence  of  the  bronchial  secretion,  cough,  etc.  The  method 
also  has  the  advantage  of  requiring  but  Httle  ether  to  induce  and  main- 
tain anesthesia,  and  there  is  practically  no  stage  of  excitement  or 
postoperative  nausea  and  vomiting.  On  the  other  hand,  the  induc- 
tion of  narcosis  is  slow,  and,  in  some  cases  where  the  absorptive  power 
of  the  rectum  is  hmited,  enough  of  the  drug  is  not  taken  into  the 
system  to  keep  the  patient  under,  so  that  other  means  of  anesthetizing 
must  be  utilized.  It  is  not  a  suitable  method  to  employ  in  abdominal 
operations  on  account  of  the  distention  produced,  nor  should  it  be 
used  if  the  intestines  are  inflamed  or  their  walls  weakened. 


Fig.  34. — Apparatus  for  rectal  anesthesia. 

Apparatus. — The  necessary  apparatus  consists  of  the  following: 
A  wash  bottle  to  hold  the  ether,  about  8  inches  (20  cm.)  high  and  4 
inches  (10  cm.)  in  diameter,  supplied  with  a  tight  stopper  in  which 
are  two  perforations.  Through  one  of  these  openings  a  glass  tube 
leads  to  the  bottom  of  the  bottle,  and  through  the  other  a  glass  tube, 
cut  off  flush  with  the  under  surface  of  the  stopper,  leads  out.  A 
double  cautery  bulb  is  attached  to  the  aft'erent  tube  by  a  piece  of 
rubber  tubing,  while  to  the  efferent  tube  is  connected  a  piece  of  rubber 
tubing  leading  to  a  plain  rectal  tube,  a  glass  bulb  being  interposed  be- 
tween the  rectal  tube  and  the  rubber  tubing  to  catch  any  condensed 
ether  vapor  and  prevent  it  from  entering  the  rectum.  Both  the  affer- 
ent and  the  eft'erent  tubes  should  be  of  sufficient  length  to  permit  the 


46  THE   ADMINISTRATION   OF    GENERAL   ANESTHETICS 

apparatus  to  be  moved  to  a  distance  from  the  patient  if  necessary. 
The  ether  bottle  is  surrounded  by  a  metal  container  holding  warm 
water.  This  should  be  kept  at  a  temperature  of  about  90°  F.  (32° 
C),  but  not  much  above,  as  the  ether  will  boil  at  96°  F.  (35°  C). 
A  thermometer  should  be  provided  for  the  purpose  of  regulating 
the  temperature.  By  compressing  the  cautery  bulb  air  is  forced 
into  the  ether  through  the  long  tube  and  leaves  the  apparatus  satu- 
rated with  warm  ether  vapor. 

Preparation  of  the  Patient. — A  thorough  cleansing  of  the  bowels  is 
absolutely  necessary,  otherwise  absorption  cannot  take  place  and  the 
first  essential  of  the  anesthesia  is  defeated.  A  cathartic  is  given  to 
the  patient  the  night  before  the  operation,  and  on  the  following 
morning  a  colonic  irrigation,  followed  by  an  ordinary  soapsuds 
enema  an  hour  before  the  operation,  complete  the  preparations. 

Technic. — The  patient  lies  upon  the  table  with  one  thigh  elevated 
upon  a  sand-bag  so  as  to  afford  room  to  insert  the  tube,  etc.  The 
bottle  is  filled  about  two-thirds  with  ether,  leaving  one-third  of  its 
capacity  for  vapor,  and  the  apparatus  is  tested  to  see  that  it  works 
properly.  The  rectal  tube,  well  lubricated,  is  inserted  8  to  10 
inches  (20  to  25  cm.)  within  the  bowel,  and  the  ether  vapor  is  forced 
in  by  means  of  gentle  compressions  of  the  rubber  bulb  every  five  to 
ten  seconds.  As  the  rectum  becomes  distended,  the  forefinger  should 
be  inserted  alongside  the  tube  into  the  bowel  to  permit  the  gases 
already  present  to  escape,  otherwise  the  absorption  of  the  vapor  is 
interfered  with;  on  complaints  of  distention,  the  superfluous  vapor 
must,  likewise,  be  allowed  to  escape. 

In  from  three  to  five  minutes  the  odor  of  the  drug  will  be  distin- 
guished in  the  patient's  breath,  and  the  patient  soon  begins  to  feel 
drowsy.  The  breathing,  at  first  rapid,  becomes  regular  and  finally 
slightly  stertorous,  and  the  patient  then  passes  into  complete  surgical 
narcosis,  generally  without  the  preliminary  stage  of  excitement.  The 
time  necessary  for  this  varies  from  five  to  fifteen  minutes,  according 
to  the  patient  and  the  absorption  power  of  the  bowel.  The  anesthetic 
cannot  be  pushed,  however,  for  the  more  the  bowel  is  distended 
beyond  a  certain  point  the  less  is  the  absorption.  As  soon  as  anes- 
thesia is  complete  it  may  be  maintained  by  gently  squeezing  the  bulb 
every  minute  or  so.  The  same  signs  as  to  the  depth  of  anesthesia, 
condition  of  the  patient,  etc.,  should  guide  the  anesthetist  as  in  the 
administration  of  pulmonary  anesthesia,  and  the  same  precautions 
about  keeping  the  tongue  and  the  jaw  forward  should  be  observed. 
At  the  completion  of  the  anesthesia,  the  rectal  tube  is  disconnected 


SPECIAL   METHODS    OF    ANESTHESIA  47 

from  the  apparatus,  and,  by  gentle  abdominal  massage  of  the  colon, 
the  vapor  remaining  unabsorbed  is  forced  out.  This  should  be  fol- 
lowed by  a  cleansing  enema. 

OiI=ether  Colonic  Anesthesia. — Recently  Gwathmey  of  New 
York  has  developed  a  method  of  rectal  anesthesia  by  means  of  a 
mixture  of  olive  oil  and  ether  injected  into  the  rectum  to  which  he 
applies  the  name  "oil-ether  colonic  anesthesia"  (N.  Y.  Medical 
Journal,  Dec.  6,  19 13).  Up  to  the  present  writing  this  method 
of  anesthesia  has  been  used  in  something  over  100  cases  and,  while 
it  may  be  said  to  be  still  in  the  experimental  stage,  it  promises 
to  be  a  most  valuable  addition  to  the  field  of  anesthesia.  The 
method  is  especially  useful  in  operations  about  the  head  and  neck, 
though  it  has  been  used  in  a  great  variety  of  operations.  According 
to  Gwathmey,  it  is  contraindicated  in  cohtis,  hemorrhoids,  fistula  in 
ano,  or  other  pathological  conditions  of  the  lower  bowel,  and  in  most 
cases  where  ether  is  contraindicated.  Under  this  form  of  anesthesia 
there  is  complete  relaxation,  the  reflexes  remain  active,  and  there  is 
an  absence  of  nausea.  For  from  one  to  three  hours  following  the 
anesthesia  there  is  a  pain-free  period.  So  far  no  diarrhea  or  bloody 
stools  or  other  untoward  effects  have  been  observed. 

Apparatus. — The  necessary  equipment  is  very  simple,  consisting 
of  a  catheter  and  funnel  for  introducing  the  oil  and  ether  mixture  and 
two  small  rectal  tubes  for  emptying  and  irrigating  the  colon. 

Solutions  Used. — A  mixture  of  ether  in  olive  oil  is  employed  in 
the  following  strengths:  For  cases  over  fifteen  years  of  age  a  75  per 
cent,  mixture;  for  children  of  from  six  to  twelve  years  of  age  a  55  to 
65  per  cent,  mixture;  and  for  those  under  six  years  of  age  a  50  per 
cent,  mixture. 

Quantity. — One  ounce  (30  c.c.)  of  the  mixture  is  administered  for 
each  20  pounds  (8  K.)  of  weight. 

Preparations  of  Patient. — The  usual  preparations  as  for  any  anes- 
thetic are  carried  out,  and  the  colon  is  irrigated  until  the  fluid  returns 
clear.  For  adults  a  preliminary  hypodermic  injection  of  1/8  to 
1/4  gr.  (0.0081  to  0.0162  gm.)  of  morphin  and  i/ioo  gr.  (0.00065 
gm.)  of  atropin  is  given  half  an  hour  before  operation  and  at  the  same 
time  5  gr.  (0.3  gm.)  of  chloretone  in  2  drams  (8  c.c.)  of  olive  oil  and 
2  drams  (8  c.c.)  of  ether  is  introduced  into  the  rectum.  For  children 
preliminary  medication  is  generally  omitted,  as  the  weaker  solutions 
are  not  irritating  to  the  bowel. 

Technic. — The  anesthetic  mixture  is  introduced  into  the  bowel 
while  the  patient  is  in  bed  in  the  Sims  position.     The  small  catheter, 


48  THE   ADMINISTILA.TION   OF    GENERAL   ANESTHETICS 

well  lubricated,  is  inserted  a  few  inches  into  the  rectum  and  the  desired 
quantity  of  solution,  depending  upon  the  weight  of  the  patient,  is 
slowly  poured  into  the  funnel.  About  five  minutes  should  be  con- 
sumed in  introducing  8  ounces  (250  c.c),  the  quantity  generally 
required  for  an  adult  of  ordinary  size.  The  tube  should  be  left  in 
place  until  the  patient  is  partially  unconscious.  In  from  five  to 
twenty  minutes  the  anesthesia  is  estabhshed.  During  the  anesthesia 
the  anesthetist  should  keep  the  air  passages  free  and  the  jaw  well  for- 
ward and  should  keep  careful  watch  over  the  general  condition  of  the 
patient.  Should  the  patient  become  too  deeply  under  the  influence 
of  the  anesthetic,  shown  by  cyanosis,  shallow,  embarrassed  or  ster- 
torous respirations,  a  rectal  tube  is  introduced  and  2  to  3  ounces 
(60  to  90  c.c.)  of  solution  are  withdrawn. 

At  the  completion  of  the  operation,  two  small  rectal  tubes  are 
passed  well  up  in  the  bowel  and  the  latter  is  irrigated  with  cold  water 
soapsuds,  the  injection  being  made  through  one  tube  while  the  second 
one  permits  the  escape  of  the  washings.  Two  to  3  ounces  (60  to  90 
c.c.)  of  olive  oil  are  then  injected  into  the  rectum  to  be  retained  by  the 
patient,  and  the  tubes  are  withdrawn. 

Scopolamin-morphin  Anesthesia — Hypodermic  injections  of 
scopolamin  and  hyoscin  (which  is  claimed  to  be  chemically  the  same) 
have  been  used  quite  extensively  in  combination  with  morphin  to 
produce  anesthesia.  From  the  number  of  deaths  reported  from  this 
combination  when  used  in  large  enough  quantities  to  produce 
anesthesia  unaided,  it  would  appear  to  be  a  very  dangerous  form  of 
anesthesia,  and  up  to  the  present  time  it  has  a  higher  death  percent- 
age than  chloroform  or  ether.  In  small  doses,  however,  hyoscin 
and  morphin  may  be  used  with  good  results  as  an  adjunct  to  local 
or  general  anesthesia.  In  such  cases  they  can  be  given  as  follows: 
Hyoscin,  gr.  i/ioo  (0.00065  S^-)  ^.nd  morphin,  gr.  1/6  to  1/4 
(0.0108  to  0.0162  gm.)  by  h}^odermic,  one  hour  to  two  hours  before 
operation.  This  combination  is  more  efl&cacious  than  morphin  alone, 
and  has  the  effect  of  producing  a  drowsy  state  and  even  sleep,  which 
may  last  five  to  six  hours  after  the  operation.  It  is  contraindicated 
in  patients  with  heart  disease  or  when  there  is  a  tendency  to  pulmon- 
ary edema.  In  the  young  and  the  aged  hyoscin  and  morphin  should 
be  used  with  great  caution. 

ACCIDENTS  DURING  ANESTHESIA  AND  THEIR  TREATMENT 

The  accidents  and  dangers  that  may  arise  during  the  adminis- 
tration of  anesthetics  are  connected  with  the  respiratory  or  circulatory 


ACCIDENTS    DURING   ANESTHESIA  49 

systems  and  include  asphyxiation,  respiratory  paralysis,  and  cardiac 
paralysis.  Theoretically,  the  dangers  of  nitrous  oxid,  ether,  and 
ethyl  chlorid  are  those  to  be  expected  from  failure  of  the  respiratory 
centers,  while  the  accidents  from  chloroform  narcosis  are  primarily 
those  occurring  as  the  result  of  the  depressing  effects  of  the  drug  upon 
the  circulation.  Practically,  however,  in  severe  cases  failure  of  the 
respiratory  centers  and  circulatory  paralysis,  if  not  coincident,  pre- 
cede or  follow  one  another  in  such  rapid  sequence  that  it  is  often 
impossible  to  distinguish  between  the  two  or  to  determine  which  is 
the  primary  cause,  and  treatment  must  be  directed  toward  both 
conditions. 

Accidents  may  be  avoided  in  the  great  majority  of  cases  if  proper 
precautions  are  taken  beforehand  in  the  preparation  of  the  patient 
and  due  care  is  observed  in  the  administration  of  the  anesthetic. 
These  points  have  already  been  considered,  but  it  may  not  be  out  of 
place  to  emphasize  by  repetition  the  most  important  of  them.  Never 
allow  the  patient  to  have  food  within  three  hours  of  the  time  of  anes- 
thesia. See  that  all  foreign. bodies,  false  teeth,  plates,  etc.,  which 
might  fall  into  the  throat  and  obstruct  the  respiratory  passages  are 
removed  beforehand,  and  that  tight  bandages  or  clothing  that  might 
constrict  the  neck  or  chest  are  loosened.  When  relaxation  occurs, 
turn  the  patient's  head  to  one  side  to  allow  mucus  and  saHva  to  flow 
from  the  mouth,  and  see  that  the  tongue  does  not  fall  back  in  the 
throat  and  act  as  an  obstruction.  The  anesthetist  must  devote  his 
entire  attention  to  the  anesthesia,  taking  particular  care  to  watch  the 
respirations,  at  the  same  time  not  forgetting  to  give  due  attention  to 
the  pulse,  the  condition  of  the  eye  reflexes,  and  the  general  appearance 
of  the  patient.  The  assistant  chosen  for  this  duty  should  be  a  person 
of  large  experience  in  the  administration  of  anesthetics  so  that  he 
may  be  competent  to  interpret  danger  signs  before  they  proceed  too 
far.  If  there  is  any  doubt  as  to  the  meaning  of  a  sudden  change  in  the 
patient's  condition  or  of  unusual  symptoms,  it  is  always  better  to  err 
on  the  safe  side  and  allow  the  patient  to  partly  recover  than  to  induce 
a  deeper,  and  what  may  be  a  dangerous,  state  of  narcosis. 

Asphyxiation. — It  is  characterized  by  a  moderate  cyanosis 
or  a  marked  lividity  of  color  and  gasping  respirations.  It  may 
be  only  transient,  or  it  may  become  progressively  worse  and 
severe.  Such  a  condition  should  be  promptly  treated  by  re- 
moval of  the  cause  which  will  be  found  to  be  some  one  of  the  fol- 
lowing: coughing,  struggling,  locking  of  the  Jaws,  awkward  posi- 
tion of  the  patient,  an  improper  holding  of  the  cone,  the  so-called 

4 


50 


THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 


"  forgetfulness  to  breathe,"  falling  back  of  the  tongue  and  epiglottis, 
obstruction  to  the  air  passages  by  blood,  mucus,  saliva,  or  foreign 
bodies,  partial  or  complete  occlusion  of  the  nose  from  deformities  of 
the  bones  and  nasal  growths,  or  from  collapse  and  falling  in  of  the 
ake  nasi  during  inspiration  under  deep  narcosis. 

Treatment.— Cyanosis  due  to  coughing  or  struggling  may    be 
overcome  by  simply  removing  the  inhaler  and  permitting  the  patient 


Fig.  35. — Method  of  holding  the  jaw  forward. 

to  get  a  breath  of  fresh  air.  When  the  position  of  the  patient  is 
responsible,  it  should  be  corrected  without  delay.  If  the  cyanosis 
be  due  to  obstruction  or  partial  occlusion  of  the  nares,  the  mouth 
should  be  kept  sufficiently  open  by  means  of  a  mouth-gag  to  permit 
the  entrance  of  the  necessary  amount  of  air.  "Forgetting  to 
breathe"  is  met  by  removing  the  inhaler  and,  after  waiting  a  moment, 


Fig.  36. — Showing  the  method  of  drawing  the  tongue  and  epiglottis  forward. 

the  patient  will  in  the  majority  of  cases  take  a  breath.  If  this  is  not 
sufficient,  a  sharp  slap  upon  the  sternum  with  a  wet  towel  or  a  momen- 
tary compression  of  the  sternum  is  frequently  all  that  is  necessary. 
Failing  by  these  means,  the  jaws  should  be  held  apart  and  rhythmic 
traction  exerted  upon  the  tongue  to  excite  a  reflex  inspiration. 

Obstruction  caused  by  the  falling  back  of  the  tongue  and  epiglot- 


ACCIDENTS   DURING   ANESTHESIA 


51 


tis  is  corrected  by  properly  holding  the  lower  jaw  forward  (Fig.  35), 
or  by  traction  upon  the  tongue  by  means  of  tongue  forceps  or  a  silk 
suture.  The  most  effective  means  for  overcoming  obstruction  from 
this  cause  is  to  pass  the  index  finger  into  the  mouth  over  the  base 
of  the  tongue  and  hook  it  forward  together  with  the  epiglottis 
(Fig.  3^)- 

When  the  asphyxial  symptoms  are  due  to  obstruction  by  collec- 
tions of  fluid  in  the  throat  or  foreign  bodies,  the  patient's  head  should 
be  turned  to  one  side,  the  jaws  forced  open,  and  the  air  passages 
cleared.  Sohd  bodies  may  be  removed  by  the  finger  or  forceps.  If 
this  is  not  possible,  tracheotomy  (page  424)  should  be  performed 
without  hesitation. 

In  any  case  of  asphyxia,  if  the  cyanosis  is  severe  and  grows  pro- 


FiG.  37. — Artificial  respiration   (inspiration).     Note  the  assistant's  hands  ready 
to  make  counterpressure  over  the  lower  portion  of  the  chest. 


gressively  worse  in  spite  of  the  above  line  of  treatment,  the  anesthetic 
and  the  operation  should  be  discontinued  while  artificial  respiration, 
combined  with  inhalations  of  oxygen,  is  carried  out.  This  is  effec- 
tively performed  by  a  combination  of  the  Sylvester  and  Howard 
methods,  or  by  the  use  of  Meltzer's  insufflation  apparatus  or  some 
one  of  the  machines  made  especially  for  performing  artificial  respira- 
tion. Any  of  the  methods  of  artificial  respiration  are  useless,  how- 
ever, as  long  as  there  is  any  obstruction  in  the  air  passages,  and 
these  should  always  be  first  cleared  out,  as  previously  directed. 

In   the    absence    of    special    apparatus,  artificial    respiration  is 
carried  out  as  follows:     The  foot  of  the  operating-table  is  raised 


52 


THE   ADMINISTRATION   OF    GENERAL   ANESTHETICS 


upon  a  stool  and  the  patient  is  slid  down  so  that  the  head  hangs 
partly  over  the  edge.  The  anesthetist,  standing  at  the  patient's 
head,  takes  a  firm  hold  just  below  the  elbows  and  draws  the  arms 
upward  and  outward  until  they  are  very  nearly  perpendicular  above 
the  head  (Fig.  37).  This  thoroughly  expands  the  chest  and  pro- 
duces an  inspiration.  The  arms  are  maintained  in  this  position  for 
a  second  or  two,  to  allow  the  air  to  thoroughly  expand  the  lungs. 
Expiration  is  produced  by  the  reversal  of  the  above  maneuver, 
bringing  the  arms  downward  with  firm  pressure  against  the  chest 
wall,  while  at  the  same  time  an  assistant,  with  palms  of  the  hands 
outstretched  over  the  margins  of  the  ribs  and  epigastrium,  presses 


Fig.  38. — Artificial  respiration   (expiration).     The  operator  brings  the   patient's 
arms  firmly  against  the  chest  while  the  assistant  makes  counterpressure. 

upward  toward  the  diaphragm  (Fig.  38).  This  counterpressure 
prevents  the  effects  of  the  expiratory  maneuver  being  lost  upon 
the  diaphragm  and  abdominal  viscera.  After  another  second  or 
so,  the  assistant  suddenly  releases  the  lower  portion  of  the  chest  and 
at  the  same  time  elevation  of  the  arms  is  again  performed.  The 
movements  producing  artificial  respiration  should  be  made  as  nearly 
as  possible  at  the  rate  of  normal  respiration,  certainly  not  over  twenty 
times  a  mmute.  As  an  adjunct  to  the  above,  forcible  dilatation  of 
the  sphincter  ani  may  be  performed  for  the  purpose  of  exciting  reflex 
inspiration. 

A  favorable  response  to  treatment  is  denoted  by  a  gradual  return 
of  the  natural  color,  at  first  feeble  gasps  and  then  stronger  attempts  at 


ACCIDENTS    DURING    ANESTHESIA  53 

respiration,  and  a  return  of  the  pulse  at  the  wrist.  If,  after  five  or 
ten  minutes,  there  is  no  response  to  the  treatment,  the  prognosis  is 
exceedingly  bad,  but  the  artificial  respiration  should  be  persisted  in 
for  at  least  half  an  hour.  Deaths  from  asphyxia  alone  during  anes- 
thesia can  be  prevented  in  nearly  all  cases  by  following  the  sugges- 
tions and  the  treatment  above  described. 

Respiratory  Paralysis. — This  is  a  more  serious  condition.  In 
the  first  stages  of  anesthesia  it  may  be  due  to  a  spasm  of  the  glottis, 
diaphragm,  or  respiratory  muscles  through  reflex  irritation  from  over- 
stimulation of  the  nasal  branches  of  the  trigeminal  nerve,  when  large 
quantities  of  ether  are  suddenly  poured  upon  the  inhaler  or  the 
strength  of  the  drug  is  too  rapidly  increased.  The  patient  suddenly 
stops  breathing  and  becomes  cyanosed,  but  the  pupillary  reaction 
remains  and  the  pulse  is  usually  good;  and,  if  artificial  respiration  be 
promptly  performed,  the  danger  is  overcome. 

When  the  condition  occurs  in  the  later  stages,  after  deep  narcosis, 
it  is  the  result  of  too  much  anesthetic,  producing  paralysis  of  the 
medullary  centers,  and  is  a  more  dangerous  condition.  The  pupils 
suddenly  dilate  and  fail  to  respond  to  light,  and  the  conjunctival 
reflex  is  lost;  the  respirations  become  progressively  weaker  and  more 
superficial,  and  finally  stop.  The  patient  has  an  ashen-gray  look, 
lies  in  a  state  of  extreme  relaxation,  and  the  heart  ceases  to  beat  after 
a  few  seconds. 

Treatment. — This  is  a  condition  requiring  prompt  and  energetic 
treatment.  The  anesthetic  and  the  operation  should  be  immediately 
stopped  and  every  effort  made  to  revive  the  patient.  It  should  be 
seen  that  there  is  no  impediment  to  the  free  entrance  of  air  into  the 
respiratory  passages,  and  then  the  foot  of  the  table  should  be  elevated 
upon  a  stool,  while  artificial  respiration  is  performed  after  the  manner 
above  described  (page  52). 

Cardiac  Paralysis. — Syncope  may  occur  during  anesthesia  from 
chloroform  or  ether,  but  is  more  apt  to  be  produced  by  the  former. 
It  is  the  most  serious  of  all  the  anesthetic  accidents.  From  the  fact 
that  a  great  proportion  of  the  deaths  from  chloroform  anesthesia 
occur  in  the  early  stages,  when  only  a  small  quantity  of  the  anesthetic 
has  been  given,  it  has  been  contended  that  fright,  producing  vaso- 
motor paralysis,  is  the  cause.  There  is  no  doubt  that  fright  or  strug- 
gling during  the  early  stage  of  anesthesia  is  sufficient  in  some  cases 
to  cause  dilatation  of  the  heart  and  vasomotor  paralysis,  especially 
if  the  individual  is  already  affected  with  degenerative  changes  in  the 
heart,  or  is  suffering  from  severe  anemia  or  shock.     But  fatal  syncope 


54  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

has  occurred  in  many  cases  after  only  a  few  inhalations  of  chloroform, 
when  the  patient  was  in  strong  physical  condition  and  exhibited  no 
fear  of  the  operation  whatever.  Such  cases  and  those  occurring  after 
full  anesthesia  has  been  established  can  only  be  ascribed  to  the  toxic 
action  of  the  drug  from  sudden  overdosage. 

When  circulatory  paralysis  occurs,  the  pulse  first  becomes  weak 
and  irregular,  and  then  feeble  and  fluttering;  the  skin  becomes  pal- 
lid, the  pupils  dilate  and  remain  fixed,  and  finally  the  heart  stops 
entirely.  Irregular  attempts  at  breathing  may  continue  for  a  few 
moments  after  cessation  of  the  heart-beat.  Postmortem  examina- 
tion reveals  a  heart  dilated  and  overcharged  with  blood,  and 
general  dilatation  of  the  capillaries  and  veins,  especially  in  the  abdo- 
men, showing  that  the  patient  has  practically  bled  into  his  own 
vessels,  and  nearly  all  the  blood  is  withdrawn  from  the  cerebral 
centers. 

Treatment. — The  treatment  of  such  a  condition  should  consist 
in  artificial  respiration  and  in  adopting  means  to  overcome  the  cere- 
bral anemia  and  to  empty  the  engorged  heart.  In  the  presence  of 
signs  pointing  to  syncope,  the  treatment  should,  be  instituted 
promptly,  without  waiting  for  cessation  of  respiration.  The  foot 
of  the  table  should  be  immediately  elevated  to  an  angle  of  45  degrees, 
so  that  the  patient  is  in  an  exaggerated  Trendelenburg  position. 
Children  may  be  inverted  by  simply  holding  them  by  the  heels. 
Combined  with  position,  compression  of  the  limbs  and  abdomen  by 
means  of  bandages  may  be  employed  to  force  the  blood  from  the 
dilated  capillaries  and  splanchnic  areas.  Artificial  respiration  and 
oxygen  inhalations  should  be  employed  from  the  start,  as  already 
described.  Massage  of  the  heart  for  the  purpose  of  emptying  it  of 
the  engorged  blood  should  also  be  practised. 

External  cardiac  massage  maybe  readily  carried  out  with  the  hand 
placed  over  the  precordium  by  elevating  and  depressing  the  wrist- 
joint  at  about  the  rate  of  the  normal  beat.  In  abdominal  operations 
the  heart  may  be  massaged  by  grasping  it  between  the  thumb  and 
forefinger,  through  the  relaxed  diaphragm,  and  alternately  compress- 
ing and  relaxing  it  twenty  to  forty  times  a  minute.  Direct  cardiac 
massage  can  be  practised  through  an  incision  in  the  fourth  intercostal 
space  and  opening  the  pericardium.  This  operation  has  been  suc- 
cessfully performed  in  some  seemingly  hopeless  cases,  and  is  worthy 
of  trial. 

Cardiac  stimulants,  such  as  strychnin,  are  of  little  use  until  the 
circulation  is  reestablished;  a  hypodermic  of  some  rapid  acting  drug, 


THE    AFTER-EFFECTS    OF    ANESTHESIA  55 

however,  as  adrenalin  chlorid,  5  to  2oTri  (0.30  to  1.25  c.c.)  injected 
into  a  vein,  camphorated  oil,  2oTn.  (1.25  c.c),  whisky,  2oTri  (1.25 
c.c),  etc.,  may  be  tried  with  better  chances  of  success. '  An  intra- 
venous infusion  of  hot  salt  solution,  combined  with  15  to  3oTn. 
(i  to  2  c.c)  of  a  I  to  1000  solution  of  adrenalin  chlorid  injected 
drop  by  drop  by  means  of  a  hypodermic  directly  into  the  rubber 
tube  of  the  infusion  apparatus  while  the  solution  is  flowing,  should 
be  given  by  an  assistant  while  the  other  means  of  treatment  are  being 
carried  out.  According  to  Crile's  experiments,  an  intraarterial  in- 
fusion of  adrenahn  in  salt  solution  injected  toward  the  heart  (see 
page  145)  has  more  effect  in  raising  blood-pressure  and  would  be  a 
more  rational  form  of  treatment.  When  there  is  no  improvement 
within  ten  or  fifteen  minutes,  the  case  is  usually  hopeless. 

THE  AFTER-EFFECTS  OF  ANESTHESIA 

Vomiting. — This  is  the  most  frequent  postanesthetic  complica- 
tion. The  best  way  to  avoid  it  is  by  careful  preparation  of  the 
patient  before  anesthesia  and  a  skilful  administration  of  the  anes- 
thetic. In  some  cases,  however,  it  occurs  in  spite  of  all  that  can  be 
done,  and  may  be  persistent.  That  from  chloroform  is  usually 
more  severe  and  more  difficult  to  treat. 

For  the  ordinary  vomiting,  inhalations  of  vinegar,  ice  in  small 
quantities  by  mouth,  or  very  hot  water  in  small  doses  (teaspoonfuls) 
are  the  common  remedies.  The  latter  is  most  efficient,  serving  to 
dilute  the  mucus  and  wash  out  the  stomach  contents.  Fifteen  to 
20  gr.  (i  to  1.5  gm.)  of  bicarbonate  of  soda  in  a  glass  of  warm  water 
is  also  recommended.  Likewise  pure  olive  oil  in  ounce  doses  has 
been  successfully  employed.  Cerium  oxalate,  gr.  v  (0.3  gm.),  bis- 
muth subnitrate,  gr.  v  (0.3  gm.),  acetanilid  in  i  gr.  (0.065  g^^-) 
doses  every  one-half  hour  until  8  gr.  (0.5  gm.)  have  been  taken, 
morphin,  or  small  doses  [1/12  gr.  (0.0054  gm.)]  of  cocain  every  half 
hour  up  to  I  gr.  (0.065  gm.)  may  be  used  in  the  more  troublesome 
cases.  If  the  condition  becomes  persistent  and  severe,  lavage  of  the 
stomach  (see  page  494)  should  be  carried  out  and  repeated  as  often 
as  necessary.  In  fact,  it  is  the  best  means  of  preventing  vomiting 
in  any  case,  and  some  surgeons  employ  it  as  a  routine,  having  it 
performed  while  the  patient  is  still  on  the  operating-table  before 
becoming  conscious. 

Respiratory  Complications. — These  are  seen  more  frequently 
after  ether  than  chloroform,  and  include  edema  of  the  lungs,  bron- 


56  THE    ADMINISTRATION    OF    GENERAL   ANESTHETICS 

chitis,  bronchopneumonia,  and  lobar  pneumonia.  They  should  be 
treated  along  the  lines  ordinarily  followed  in  such  cases.  Lung  com- 
plications are  especially  liable  to  follow  anesthesia  where  a  diseased 
condition  is  already  present,  as  bronchitis,  emphysema,  or  tuber- 
culosis, or  in  the  aged  or  feeble. 

To  avoid  as  far  as  possible  such  complications,  the  mouth,  nose, 
and  teeth  should  be  carefully  cleansed  before  anesthesia,  the  appa- 
ratus employed  for  administering  the  anesthetic  should  not  be  carried 
from  one  patient  to  another  without  sterilization,  and  due  care  should 
be  observed  while  administering  the  anesthetic  to  prevent  aspiration 
of  fluids  or  vomitus.  As  a  further  precautionary  measure,  the  patient 
should  always  be  carefully  protected  against  chilling,  both  during  the 
anesthesia  and  while  he  is  being  removed  to  his  bed. 

Renal  Complications. — Temporary  albuminuria  and  casts  are 
not  uncommon  after  both  ether  and  chloroform,  and,  if  a  diseased 
condition  of  the  kidneys  be  present  beforehand,  it  is  much  aggra- 
vated, though  of  the  two  drugs  chloroform  exerts  less  of  an  irritant 
action.  Scanty  excretion  of  urine  with  actual  suppression  and  hema- 
turia are  occasionally  seen.  Such  a  condition  should  be  treated  by 
mild  diuretics,  cathartics,  and  saline  rectal  irrigations. 

Postoperative  Anesthetic  Paralyses. — These  are  mostly  per- 
ipheral from  pressure  upon  some  nerve  during  the  period  of  uncon- 
sciousness, though  paralysis  of  central  origin  may  take  place  as  the 
result  of  cerebral  emboHsm  or  hemorrhage,  especially  in  those  with 
high  arterial  tension  and  degenerative  changes  in  the  blood-vessels. 
Peripheral  paralysis  may  affect  the  arm,  leg,  or  face.  Injury  to  the 
musculospiral  nerve  from  pressure  by  the  edge  of  the  table  if  the  arm 
is  allowed  to  hang  down,  and  injury  to  the  brachial  plexus  from  pres- 
sure between  the  clavicle  and  first  rib,  or  by  the  head  of  the  humerus 
when  the  arms  are  fastened  above  the  head  are  the  most  frequent 
lesions. 

Delayed  Poisoning. — Certain  of  the  late  deaths  occurring  after 
anesthesia,  that  were  formerly  supposed  to  be  due  to  sepsis,  shock,  fat 
embolism,  etc.,  are  now  known  to  be  due  to  an  acid  intoxication. 
This  condition,  variously  designated  as  cholemia,  acidosis,  aceto- 
nuria,  and  acid  intoxication,  most  frequently  follows  chloroform  nar- 
cosis and  is  more  common  among  children.  The  symptoms  do  not 
appear  until  the  patient  has  recovered  from  the  anesthesia  develop- 
ing in  from  10  to  150  hours  (Bevan  and  Favill). 

The  condition  is  characterized  by  persistent  vomiting,  jaundice, 
sweetish  breath,   rapid  pulse.   Cheyne-Stokes  respiration,  in  some 


THE    AFTER-TREATMENT    OF    ANESTHESIA  57 

cases  extreme  restlessness  and  excitability,  in  others  delirium,  con- 
vulsions, and  coma.  In  some  the  temperature  is  exceedingly  high, 
in  others  it  is  subnormal.  Death  in  fatal  cases  occurs  within  three 
to  five  days.  At  postmortem  there  is  found  a  condition  of  fatty 
degeneration  of  the  kidneys,  heart  muscle,  and  hver,  most  marked 
in  the  latter,  and  at  times  actual  necrosis  of  the  Hver  is  seen.  This 
condition  is  the  result  of  the  destructive  action  of  chloroform  upon  the 
cells.  The  insufficiency  of  the  hver  results  in  the  accumulation  of 
toxins,  and  acetone,  diacetic  acid,  and  oxybutyric  acid  appear  in  the 
blood  and  urine  as  by-products. 

Bicarbonate  of  soda  given  by  mouth  in  mild  cases,  and  in  salt 
solution  by  rectum,  by  hypodermoclysis,  or  intravenously  in  the 
severer  ones,  seems  the  most  valuable  remedy  for  this  condition.  For 
intravenous  injection  i  1/2  ounces  (45  gm.)  of  bicarbonate  of  soda 
is  dissolved  in  i  quart  (liter)  of  normal  salt  solution  [salt  5  ii  (8  gm.) 
to  the  quart  (1000  c.c.)  of  water],  and  1/2  pint  (250  c.c.)  is  admin- 
istered every  three  or  four  hours  until  the  entire  amount  is  injected. 
In  addition,  free  ehmination  by  the  skin  should  be  encouraged,  and 
the  bowels  should  be  kept  freely  open. 

THE  AFTER-TREATMENT  OF  CASES  OF  GENERAL 
ANESTHESIA 

Before  moving  a  patient  from  the  operating-table  to  his  bed,  it 
should  be  seen  that  he  is  well  protected  and  properly  wrapped  in  warm 
dry  blankets.  During  the  process  of  moving,  care  should  be  taken 
not  to  elevate  the  head  or  chest.  The  recovery  room  should  be  well 
ventilated,  but  the  patient  should  be  protected  from  any  draughts. 
The  bed  should  have  been  previously  prepared  and  well  warmed  by 
means  of  hot-water  bags,  which  are  to  be  removed,  however,  when  the 
patient  is  received,  unless  there  is  some  special  indication  for  their 
use,  as  in  shock  or  collapse.  If  used,  hot- water  bags  should  always 
be  covered  with  flannel  and  care  should  be  taken  to  see  that  they  are 
not  hot  enough  to  burn  the  patient. 

The  best  position  for  the  patient  is  flat  upon  the  back,  with  the 
head  level  or  a  little  lower  than  the  body,  and  with  the  face  turned 
to  one  side.  If  vomiting  occurs,  the  patient  should  be  turned 
slightly  to  one  side  and  the  vomitus  received  in  a  basin,  after  which 
the  mouth  should  be  wiped  out.  Frequent  rinsing  of  the  mouth 
with  warm  water  may  be  practised  if  the  patient  is  conscious,  and 
will  be  found  to  be  very  grateful.     The  patient  should  be  watched 


58 


THE    ADMINISTRATION    OF    GENERAL    ANESTHETICS 


by  an  attendant  until  consciousness  returns,  for,  if  left  alone,  he  may- 
choke  from  mucus  or  vomited  material  collecting  in  the  throat,  or 
attempt  to  sit  up,  remove  his  dressings,  or  in  other  ways  do  himself 
harm.  Delirious  patients  should  be  gently  restrained,  but  not  tied 
in  bed.  Inhalations  of  oxygen  or  vinegar,  and  washing  the  patient's 
face  in  cold  water,  are  of  aid  in  arousing  to  consciousness. 

The  patient  should  not  be  allowed  to  sit  up  for  at  least  six  hours. 
Small  quantities  of  hot  water  or  cracked  ice  are  given  in  the  first 
few  hours,  but  no  food  is  allowed  within  six  hours,  and  not  then 


Fig.  39.  —  The  ether  bed. 

unless  the  patient  has  stopped  vomiting.  In  cases  of  collapse,  or 
for  patients  who  are  very  weak,  nutrient  or  stimulating  enemata 
may  be  prescribed  to  sustain  the  patient  until  food  can  be 
taken.  The  first  food  taken  by  mouth  should  be  liquid  in  character, 
consisting  of  broth,  beef  tea,  or  soup.  If  this  is  retained,  other 
articles  of  soft  diet  should  be  added,  until  the  ordinary  diet  is  being 
taken.  It  is  important  to  have  the  urine  examined  for  several  days 
after  anesthesia,  and  after  the  use  of  chloroform  special  reference 
should  be  paid  to  detecting  the  presence  of  acetone  or  diacetic  acid. 


CHAPTER  II 
LOCAL  ANESTHESIA 

By  local  anesthesia  is  understood  the  abolition  of  pain  sensation 
in  a  chosen  region,  without  the  production  of  unconsciousness. 
Analgesia  is  a  more  correct  term  to  apply  to  this  variety  of  anesthesia, 
but  usage  has  so  perpetuated  the  term  "local  anesthesia"  that  it  will 
be  employed  in  these  pages. 

The  introduction  of  cocain  by  Koller,  in  1884,  first  made  possible 
local  anesthesia  as  it  is  employed  at  the  present  time,  compression  of 
the  nerve  trunks  supplying  the  field  of  operation  by  means  of  a 
tourniquet,  and  the  application  of  cold  to  the  part,  being  the  methods 
most  frequently  resorted  to  previously.  A  further  impetus  was 
given  to  the  development  of  local  anesthesia  by  the  discovery  that 
infiltration  with  cocain,  or  similar  anesthetic  agents,  into  or  around  a 
nerve  trunk  in  any  part  of  its  course  effectually  blocked  the  sensa- 
tion in  the  region  supplied  by  that  particular  nerve  peripheral  to  the 
point  of  injection.  The  introduction  by  Schleich  of  the  method  of 
infiltrating  the  tissues  with  weak  anesthetic  solutions  was  another 
important  step  and  one  that  made  possible  the  safe  employment  of 
cocain  in  really  extensive  operations. 

Through  improvement  in  the  technic  of  the  methods  of  infiltra- 
tion and  nerve  blocking  much  progress  has  been  made  in  the  last  few 
years  in  enlarging  the  field  of  local  anesthesia  until  it  can  now  be 
employed  with  entire  success  in  a  large  number  of  major  operations, 
as  weU  as  the  usual  minor  ones.  Indeed,  it  is  safe  to  say  that  fully 
half  the  operations  performed  at  the  present  time  under  general 
narcosis  could  be  as  satisfactorily  carried  out  under  local  methods 
intelHgently  used. 

In  the  choice  between  local  and  general  anesthesia  for  any  given 
case,  the  question  to  be  decided  is  whether  under  local  anesthesia 
pain  sensibility  can  be  entirely  aboHshed  and,  at  the  same  time, 
sufficient  muscular  relaxation  be  obtained  to  insure  the  proper  per- 
formance of  the  procedures  contemplated.  If  these  condidons  can 
be  satisfactorily  obtained,  and  if  the  operator  possess  the  necessary 
experience  and  skill  in  its  use,  then  local  anesthesia  should  be  offered 

59 


6o  LOCAL   ANESTHESIA 

to  the  patient,  if  for  no  other  reason,  simply  to  avoid  the  well-known 
unpleasant  after-effects  of  general  narcosis,  and  to  obtain  a  less  dis- 
turbed and  more  rapid  recovery,  regardless  of  whether  the  particular 
operation  be  classified  as  a  major  or  a  minor  one. 

Advantages  and  Disadvantages  of  Local  Anesthesia. — There  are 
certain  advantages  peculiar  to  local  anesthesia  that  should  be  care- 
fully considered  when  selecting  the  anesthetic  in  any  given  case. 
Most  important  is  the  absolute  safety  to  the  Ufe  of  the  patient  when 
this  form  of  anesthesia  is  employed  with  proper  precautions.  With 
the  substitution  of  the  weak  for  the  old-time  strong  cocain  solutions, 
and  the  discovery  of  the  newer  less  toxic  analgesics,  together  with  a 
knowledge  of  the  amount  of  these  drugs  that  can  be  safely  used,  the 
dangers  of  poisoning  may  be  disregarded. 

Furthermore,  under  local  anesthesia,  shock  is  lessened,  and  the 
depression  observed  after  the  use  of  general  narcosis  is  absent  to  a 
marked  degree,  so  that  this  form  of  anesthesia  becomes  the  method 
of  choice  when  an  anesthetic  is  required  for  those  in  collapse  or  with 
lowered  vitality.  This  is  especially  true  when  the  nerve-blocking 
method  is  employed,  for  it  is  well  known  that  cocain  injected  into  a 
nerve  effectually  blocks  the  passage  of  all  shock-producing  impulses 
along  that  particular  nerve.  As  Crile  puts  it:  "As  no  impulses  of 
any  kind  can  pass  either  upward  or  downward,  there  is  no  more 
shock  in  dividing  the  tissues,  even  the  nerve  trunks  thus  "blocked," 
than  in  dividing  the  sleeve  of  the  patient's  coat."  The  value  of  this 
principle  is  so  well  established  that  the  injection  of  cocain  into  nerve 
trunks  supplying  a  region  of  operation  is  frequently  performed 
for  the  purpose  of  preventing  shock  even  where  general  anesthesia  is 
employed,  as,  for  example,  the  preliminary  blocking  of  the  sciatic 
nerve  in  hip  amputations. 

Under  local  anesthesia  the  postoperative  blood  changes  and  the 
kidney,  heart,  and  lung  complications  are  all  avoided,  while  the 
unpleasant  after-effects  that  pertain  to  general  anesthesia  are  re- 
duced to  a  mimimum.  The  avoidance  of  vomiting  is  especially  im- 
portant for  the  proper  healing  of  wounds,  and  the  prevention  of 
such  complications  as  hernia.  A  further  advantage  in  operat- 
ing under  local  methods  is  that  the  most  favorable  conditions 
for  primary  union  are  obtained,  for,  as  gentleness  in  handling  tissues 
is  essential  for  the  successful  employment  of  this  method  of  anes- 
thesia, the  minimum  amount  of  trauma  will  be  inflicted  upon  the 
tissues. 

Another  feature  connected  with  an  operation  under  local  anes- 


LOCAL    AXESTHESLA.  6 1 

thesia  is  that  it  does  away  with  the  necessity  for  an  anesthetist,  and 
often  of  any  kind  of  an  assistant — a  very  important  consideration 
under  some  circumstances. 

In  certain  operations — hernia,  for  example — there  is  a  distinct 
advantage  in  having  the  patient  conscious,  that  he  may  demonstrate 
the  protrusion  by  coughing.  On  the  other  hand,  in  some  cases 
consciousness  and  the  knowledge  of  what  is  going  on  is  of  distinct 
disadvantage,  and  in  nervous  or  hysterical  individuals  it  may  become 
a  contraindication,  depending  upon  the  control  the  operator  has  over 
his  patient. 

There  is  no  doubt  that  it  requires  more  time  to  operate  under 
local  than  under  general  anesthesia,  and  that  it  necessitates  the  pos- 
session of  patience  and  tact  upon  the  part  of  the  operator.  As 
Matas  obser\^es,  ''it  is  this  tax  upon  the  operator's  attention,  and  the 
vigilance  required  to  keep  the  inhibitory  powers  of  the  patient  under 
control,  and  the  time  consumed  in  the  anesthetizing  procedure  that 
will  prevent  cocain  and  the  local  analgesics  from  gaining  ascendency 
in  the  crowded  amphitheaters  of  popular  teachers  where  quick  and 
brilliant  work  is  expected  by  an  impatient  audience."  This  incon- 
venience to  which  the  operator  is  subjected,  coupled  with  the  general 
uniamiliarity  with  the  proper  technic,  probably  accounts  for  the  fact 
that  the  -wide  scope  of  local  anesthesia  is  not  more  generally  taken 
advantage  of  at  the  present  time. 

Suitable  Cases. — Besides  the  minor  surgical  procedures,  such  as 
the  incision  of  an  abscess,  exploratory  puncture,  removing  small 
cysts,  amputating  toes  or  fingers,  performing  circumcisions,  etc., 
major  operations  of  any  magnitude  and  extent  may  be  performed, 
provided  the  region  is  capable  of  being  anesthetized  by  infiltration 
or  nerve  blocking. 

For  the  removal  of  practically  ail  benign  growths  such  as  lipo- 
mata,  wens,  cysts,  benign  tumors  of  the  breast,  and  for  the  removal  of 
superficial  isolated  glands,  local  anesthesia  is  quite  sufficient. 
Whether  tuberculous  glands  of  the  neck  should  be  attempted  under 
local  anesthesia  will  depend  upon  their  extent.  If  we  can  be  sure 
there  are  but  one  or  two  superficial  glands,  it  may  be  readily  done, 
but  in  the  writer's  opinion  it  is  rarely  possible  to  define  the  extent  of 
these  operations  beforehand,  and  it  is  not  an  uncommon  experience 
in  apparently  simple  cases  Avhen  the  field  of  operation  is  thoroughly 
exposed  to  find  a  chain  of  matted  glands  requiring  deep  and  wide 
dissection  for  their  removal.  For  the  same  reasons,  and  because  the 
limits  of  the  disease  are  not  well  defined  when  the  tissues  are  swollen 


62  LOCAL   ANESTHESIA 

by  the  infiltrated  fluid  local  anesthesia  is  not  as  a  rule  suitable  for 
the  removal  of  malignant  growths. 

Amputations  of  any  of  the  limbs  may  be  performed  if  the  large 
sensory  nerves  are  properly  blocked.  By  means  of  a  preliminary  co- 
cainization  of  the  sciatic  and  anterior  crural  nerves,  amputation  of 
the  leg  has  been  often  painlessly  performed  when  a  general  anesthetic 
was  contraindicated.  The  same  principle  applies  to  amputations  of 
other  limbs. 

]\Iany  of  the  operations  upon  the  superficial  bones,  such  as  wiring 
and  plating  fractures  and  rib  resections,  may  be  painlessly  performed 
if  the  periosteum  as  well  as  the  more  superficial  tissues  are  rendered 
insensible  by  proper  infiltration.  Thus  fractures  of  the  lower  jaw, 
the  clavicle,  the  olecranon,  and  the  patella  can  readily  be  operated 
upon  by  local  methods.  The  latter  operation  lends  itself  especially 
to  local  anesthesia  on  account  of  the  superficial  position  of  the  bone 
and  the  scarcity  of  sensory  nerves  in  that  region. 

For  the  majority  of  abdominal  operations  local  anesthesia  is  not 
satisfactory.  It  is  not  that  there  is  any  difficulty  in  entering  the 
abdominal  cavity — this  can  be  very  readily  done  under  careful  in- 
filtration of  the  various  layers  of  the  abdominal  wall — but  the  trouble 
is  in  meeting  the  various  comphcations  that  may  be  present.  We 
know  that  the  abdominal  organs  are  insensible  to  pain,  but  the 
parietal  peritoneum  is  most  sensitive,  especially  if  inflamed.  The 
separation  of  adhesions  and  procedures  that  require  dragging  upon 
the  mesentery  are  likewise  painful.  Exploratory  operations  and  pro- 
cedures, such  as  colostomy,  gastrostomy,  gastrotomy,  simple  drain- 
age of  the  gall-bladder  and  appendiceal  abscess,  suprapubic  cystotomy, 
suture  of  the  intestines  following  typhoid  perforation,  appendicostomy , 
and  some  interval  operations  for  appendicitis,  requiring  but  little 
intraabdominal  manipulation,  can  be  readily  performed  without  a 
general  anesthetic;  but  when  extensive  manipulation  is  required, 
with  the  separation  of  adhesions  necessitating  more  or  less  pulhng 
upon  the  mesentery,  local  anesthesia  is  contraindicated.  Further- 
more, in  abdominal  surgery  complete  muscular  relaxation  is  usually 
required  to  secure  the  necessary  wide  retraction,  and  this  cannot 
always  be  obtained  under  local  anesthesia. 

Local  anesthesia  is  ideal  in  the  operations  for  inguinal  hernia  on 
account  of  the  superficial  location  of  the  structures  involved  and  the 
definite  position  and  course  of  the  sensory  nerve  trunks  supplying  the 
region  of  operation.  Other  forms  of  hernia  may  be  operated  upon 
by  employing  infiltration  alone,  but  not  with  the  entire  satisfaction 


LOCAL   ANESTHESIA  63 

obtained  in  the  inguinal  variety.  For  strangulated  hernia  of  any 
variety,  local  anesthesia  should  always  be  the  choice.  The  addi- 
tional strain  of  general  anesthesia  upon  these  patients,  already  toxic, 
frequently  produces  more  depression  than  they  can  withstand,  and, 
as  there  is  no  need  for  haste,  abundance  of  time  may  be  taken  in 
attempts  at  restoration  of  gut  of  doubtful  vitality,  without  adding 
a  particle  to  the  shock  of  the  operation. 

Tracheotomy,  thyroidectomy,  the  ligation  of  blood-vessels,  the 
repair  of  the  perineum  and  cervix,  and  any  of  the  operations 
about  the  scrotum,  as  those  for  castration,  varicocele,  or  hydrocele, 
are  all  amenable  to  local  anesthesia.  Quite  extensive  operations 
about  the  rectum  have  been  performed  by  some  operators  under 
local  anesthesia,  but  for  most  of  the  work  in  this  region  thorough 
stretching  of  the  sphincter  ani  is  essential,  and  this  cannot  be  per- 
formed painlessly  by  this  method;  for  this  reason  it  is  unsuitable  in 
the  majority  of  cases.  However,  simple  operative  procedures,  such 
as  those  for  fissure,  external  and  thrombotic  hemorrhoids,  and  straight 
uncomplicated  fistulae  are  within  the  scope  of  local  anesthesia. 

By  a  skilful  use  of  local  anesthesia  in  the  hands  of  one  thoroughly 
familiar  with  the  technic  of  infiltration  and  nerve  blocking,  this  list 
may  be  considerably  enlarged.  Furthermore,  it  should  not  be 
forgotten  that  in  many  operations  too  painful  for  local  anesthesia 
alone,  the  major  portion  of  the  operation  may  be  performed  under 
local  methods,  and  then  nitrous  oxid  gas  or  a  small  quantity  of  ether 
may  be  administered  to  tide  the  patient  over  the  more  painful  pro- 
cedures, thus  avoiding  a  prolonged  general  narcosis. 

Those  cases  in  which  local  anesthesia  is  impracticable  have  been 
already  indicated  in  a  general  way.  In  addition,  for  young  children, 
for  those  who  are  greatly  excited  or  hysterical,  and  for  insane  or 
delirious  individuals,  local  anesthesia  is  generally  contraindicated, 
or  at  best  it  is  very  unsatisfactory  on  account  of  the  difficulty  of 
obtaining  the  necessary  quietude. 

Methods  of  Producing  Local  Anesthesia. — At  the  present  time 
two  methods  of  producing  local  anesthesia  are  recognized:  (i)  The 
use  of  agents  which  freeze  the  tissues,  and  (2)  the  use  of  chemical 
anesthetics  or  analgesics,  of  which  cocain  is  a  type.  Freezing  of  the 
tissues  has  a  very  limited  field  of  usefulness — practically  none  in 
major  surgery — and  it  is  upon  some  of  the  analgesic  agents  that  we 
have  to  rely  largely. 

The  methods  of  employing  anesthetics  may  be  in  turn  divided 
into  two  classes:     (i)  Where  the  drug  is  used  in  such  a  way  that  the 


64  LOCAL   ANESTHESIA 

endings  of  the  sensory  nerves  are  paralyzed  (terminal  anesthesia) ;  and 
(2)  where  the  drug  is  brought  in  contact  with  a  nerve  trunk  in  some 
part  of  its  course,  thereby  blocking  the  sensory  conductivity  of  that 
particular  nerve  and  rendering  the  area  supplied  by  it  devoid  of 
sensation  (regional  anesthesia).  To  the  first  class  belong  the  topical 
application  of  analgesic  drugs  to  mucous  membranes,  and  their 
injection  into  the  tissues  (infiltration  anesthesia),  though  by  this 
latter  method  a  mixture  of  terminal  and  regional  anesthesia  is  often 
produced;  while  regional  anesthesia  may  be  produced  by  the  injec- 
tion of  analgesics  into  a  nerve  trunk  (endoneural  infiltration),  about 
a  nerve  trunk  (perineural  infiltration),  into  the  subarachnoid  space 
(spinal  anesthesia),  or  into  the  extradural  space.  Another  method 
of  producing  local  anesthesia,  termed  venous  anesthesia,  has  lately 
been  introduced  by  Bier,  whereby  the  analgesic  agent  is  injected 
into  the  venous  system  and  is  thus  brought  in  contact  with  the  nerve 
trunks  and  nerve  endings.  This  method  of  anesthesia  is  a  combina- 
tion of  terminal  and  regional  anesthesia. 

Drugs  Employed  for  Local  Anesthesia. — Cocain. — Of  the  many 
local  anesthetics  cocain  was  the  first  employed  and  holds  the  most 
important  place,  having  successfully  stood  the  test  of  time.  When 
applied  to  the  unbroken  skin  it  is  without  effect,  but  in  contact  with 
mucous  membranes  it  completely  deadens  sensibility  within  a  few 
moments.  Injected  into  the  tissues,  cocain  produces  anesthesia 
within  the  area  of  contact;  when  injected  into  or  about  a  sensory 
nerve,  it  is  rapidly  absorbed  and  produces  complete  insensibility  in  the 
whole  distribution  of  the  nerve  peripheral  to  the  point  of  injection. 

Solutions  of  cocain  should  always  be  freshly  prepared  at  the  time  of 
operation,  as  it  is  well  known  that  they  are  prone  to  decompose,  and 
in  a  short  time  such  a  solution  becomes  capable  of  producing  sup- 
puration. A  medium  isotonic  with  the  fluids  of  the  body,  as  normal 
salt  solution,  is  the  best  for  dissolving  the  cocain.  Such  a  solution, 
producing  neither  swelling  of  the  tissues,  as  water  does,  nor  shrinkage 
of  the  cells,  as  is  the  case  with  the  more  concentrated  saline  solutions, 
has  no  injurious  effects  upon  the  tissues.  The  effectiveness  of  the 
solution  is  also  increased  by  using  it  warm. 

As  solutions  of  cocain  will  not  stand  prolonged  boiling,  the  salt  or 
tablet  should  be  previously  sterilized  by  dry  heat.  An  efficient 
method  is  to  place  the  cocain  in  a  small  test-tube  plugged  with  cotton, 
and  then  to  sterilize  it  by  means  of  dry  heat  at  a  temperature  of  300° 
F.  for  fifteen  minutes.     Several  firms^  prepare  hermetically  sealed 

'  Parke,  Davis  &  Co.,  and  Squibbs. 


LOCAL   ANESTHESIA 


65 


glass  tubes  of  sterilized  salt  and  cocain  according  to  Bodine's  formula, 
each  tube  containing  2  4/5  gr.  (0.18  gm.)  of  sodium  chlorid  and  i 
gr.  (0.065  gm.)  of  cocain  muriate.  The  contents  of  one  of  these  tubes 
dissolved  in  an  ounce  (30  c.c.)  of  sterile  water  gives  approximately  a 
I  to  500  solution  of  cocain  in  normal  salt  solution.  Alkalis  render 
cocain  inert.  For  this  reason  soda  should  not  be  put  in  the  water  in 
which  the  syringes,  needles,  and  solution  glasses  are  boiled. 

Solutions  of  cocain  used  in  the  following  strength  will  be  found 
amply  strong  for  the  purpose  for  which  they  are  recommended.  For 
anesthetizing  the  skin  and  for  perineural  injections,  a  i  to  500  (1/5 
of  I  per  cent.)  solution;  for  deeper  infiltration,  a  i  to  1000  (i/io  of 

1  per  cent.)  solution;  for  massive  infiltration,  a  i  to  3000  (1/30  of  i 
per  cent.)  solution;  and  for  endoneural  injections,  10  to  30111  (0.6  to 

2  c.c.)  of  a  I  to  200  (1/2  of  I  per  cent.)  solution  are  employed. 
Schleich  has  three  solutions  containing  a  combination  of  cocain, 
morphin,  and  sodium  chlorid: 


No.  I,  strong 

No.  2,  medium 

No.  3,  weak 

Cocain  hydrochlor- 

gr.  3     (0.2     gm.)      gr.  i  1/2  (c.i  gm.) 

gr.  1/6  (o.oi  gm.) 

ate. 

Morphin       hydro- 

gr.  1/3    (0.02  gm.)    gr.  1/3  (0.02  gm.)|  gr.  1/12  (0.005 

chlorate. 

gm-) 

Chlorid  of  sodium 

gr.  3   (0.2  gm.)        i  gr.  3  (0.2  gm.) 

gr.  3  (c.2  gm.) 

Distilled  sterilized 

oz.  3  1/3  (100  c.c.)  oz.  3  1/3  (100  c.c.) 

oz.  3  1/3  (100  c.c.) 

water. 

The  strong  solution  is  used  for  the  skin,  perineural  injections, 
etc.  An  ounce  (30  c.c.)  may  be  used  without  risk.  Of  the  medium 
strength  solution,  used  for  ordinary  infiltration  of  the  tissues  below 
the  skin,  2  ounces  (60  c.c.)  may  be  used;  while  as  much  as  10 
ounces  (300  c.c.)  of  the  weaker  solution,  which  is  employed  for 
massive  infiltration  of  large  areas,  may  be  safely  injected.  Tablets 
according  to  the  Schleich  formulae  may  be  obtained  from  most  phar- 
macists, with  full  directions  for  the  preparation  of  a  solution  of  any 
given  strength.  Schleich's  solutions  find  favor  with  many  operators, 
but  personally  the  writer  prefers  to  administer  the  morphin  separately 
•in  a  definite  dose  by  hypodermic  half  an  hour  before  operation. 

The  addition  of  adrenalin  chlorid  to  the  cocain  solution,  as 
advocated  by  Braun,  is  of  distinct  advantage.     Adrenalin  is  a  vaso- 


66  LOCAL    ANESTHESIA 

constrictor  and  has  the  same  effect  in  the  way  of  an  adjunct  to  local 
anesthesia  as  constriction  of  the  part  has,  increasing  as  well  as  pro- 
longing the  anesthetic  effects  to  a  marked  degree.  At  the  same  time, 
by  preventing  capillary  oozing,  it  gives  a  much  drier  lield  of  opera- 
tion. With  its  use  there  is  some  danger  of  secondary  hemorrhage 
if  the  large  blood-vessels  are  not  properly  secured,  since,  owing  to  its 
styptic  action,  even  arteries  of  some  size  may  be  prevented  from 
bleeding  at  the  time  and  so  be  overlooked.  It  is  a  good  rule,  there- 
fore, to  at  least  clamp  any  vessel  that  bleeds,  however  slightly,  when 
using  adrenahn.  From  5  to  10  minims  (0.3  to  0.6  c.c.)  of  the  i 
to  1000  solution  of  adrenalin  chlorid  is  added  to  the  cocain  and  salt 
solution  before  it  is  to  be  used. 

In  the  early  history  of  its  development  cocain  was  used  in  solu- 
tions as  strong  as  10  and  15  per  cent.,  with  the  result  that  frequently 
a  set  of  dangerous  symptoms,  and  in  some  cases  death,  were  the 
sequels.  This  toxic  action  is  due  to  the  absorption  of  more  of  the 
drug  than  the  tissues  can  take  care  of.  The  amount  of  the  drug  that 
can  be  injected  into  the  tissues  with  safety  depends  upon  the  strength 
of  the  solution  as  well  as  the  method  of  injection.  To  be  well  within 
the  limits  of  safety,  not  more  than  3/4  gr.  (0.0486  gm.)  of  cocain 
should  be  allowed  to  remain  unconfined  in  the  tissues,  nor  should 
this  amount  be  exceeded  when  applied  to  mucous  membranes  from 
which  rapid  absorption  takes  place.  With  the  weaker  cocain  solu- 
tions (0.2  to  0.1  per  cent.)  it  is  rarely  necessary  to  exceed  this  amount, 
even  in  extensive  operations.  Of  course,  when  a  large  proportion  of 
the  solution  escapes,  or  when  the  circulation  is  impeded  by  constric- 
tion, a  larger  amount  may  be  used  with  safety. 

To  avoid  the  untoward  effects  of  cocain,  a  number  of  drugs,  as 
eucain  B,  tropacocain,  stovain,  alypin,  novocain,  acoin,  nirvanin, 
orthoform,  anesthesin.  quinin  and  urea  hydrochlorid,  etc.,  which  are 
less  toxic  but  have  about  the  same  action  as  cocain,  have  been  intro- 
duced as  substitutes.  Of  these,  eucain  B,  novocain,  and  quinin  and 
urea  are  probably  most  frequently  used.  These  newer  preparations 
are  preferred  by  many  operators  to  cocain,  and  they  have  the  advan- 
tage that  their  solutions  may  be  sterilized  by  boiling.  Weak  solu- 
tions of  cocain,  however,  used  with  proper  precautions,  the  writer 
has  always  found  to  be  perfectly  safe  as  well  as  efficient. 

B-Eucain. — Eucain  was  one  of  the  first  substitutes  for  cocain. 
It  is  claimed  to  be  one-fourth  as  toxic  as  cocain;  on  the  other  hand  the 
anesthetic  effect  is  slower  and  less  pronounced.  It  has  the  advan- 
tage over  cocain  that  its  solutions  may  be  boiled.     Eucain  is  a  vaso- 


LOCAL   ANESTHESIA 


67 


dilator  and  the  addition  of  adrenalin  to  its  solutions  has  not  nearly 
so  pronounced  an  effect  as  when  added  to  cocain.  The  drug  is 
generally  used  in  1/2  per  cent,  solution  with  adrenalin. 

Novocain. — Novocain,  one  of  the  more  recent  and  at  the  present 
time  the  most  popular  substitute  for  cocain,  was  introduced  in  1905. 
It  is  estimated  to  be  one-sixth  to  one-seventh  as  toxic  as  cocain.  Like 
eucain,  its  solutions  are  not  affected  by  boiling.  It  is  precipitated 
from  solution  by  free  or  carbonated  alkalis,  so  syringes,  needles,  etc., 
should  be  boiled  in  pure  water.  Used  in  conjunction  with  adrenalin 
its  anesthetic  powers  are  about  equal  to  cocain  when  injected  into  the 
tissues,  but  as  a  local  anesthetic  for  mucous  surfaces  it  is  far  inferior 
to  cocain. 

Braun  employs  four  novocain  solutions: 


No.  I 

No.  II 

No.  Ill 

No.  IV 

Novocain..  . 

3  3/4  gr.    (0.2s  gm.) 

3  3/4  gr.    (0.25   gm.) 

I  1/2  gr.    (o.i    gm.) 

I  1/2    gr.  (o.i    gm.) 

Normal    salt 

solution. 

3  1/3  oz.  (100  c.c.)      I  2/3  oz.  (50  c.c.) 

2  1/2  dr.  (10  c.c.) 

I  1/4  dr.  (5  c.c.) 

Adrenalin 

i-iooo  or  I 

Homorenonf 

5  drops 

5  drops 

5  drops 

ID  drops 

4  per  cent.  J 

No.  IV  is  employed  only  for  injecting  large  thick  nerves. 

Quinin  and  Urea  Hydrochlorid. — This  combination  was  intro- 
duced into  surgery  in  1907.  So  far  as  known,  it  has  no  toxic  effects, 
and  the  anesthesia  produced  by  it  is  a  protracted  one,  often  lasting 
four  or  five  days.  In  its  early  use  solutio  ns  of  i  per  cent,  were  employed, 
but  it  was  found  they  produced  an  exudate  of  fibrin  that  sometimes 
interfered  with  wound  healing,  so  that  at  the  present  time  the 
drug  is  employed  in  1/2  to  1/4  per  cent,  solutions.  Upon  mucous 
membranes,  solutions  of  10  to  20  per  cent,  may  be  used.  It,  how- 
ever, does  not  produce  a  shrinkage  of  the  tissues  as  cocain  does 
and  for   this  reason  is  inferior  to  it  in  nasal  work. 

Preparation  of  the  Patient. — The  usual  preparation  of  the  bowels, 
etc.,  recommended  as  preliminary  to  general  anesthesia,  is  advisable. 
There  is  no  need  for  the  patient  to  fast,  however,  and  a  light  meal  of 
eggs,  coffee,  milk,  toast,  etc.,  may  be  allowed,  unless  the  character 
of  the  operation  contraindicates  it.  If  it  seems  probable  that  a 
general  anesthetic  will  be  required  to  complete  the  operation,  the 
patient's  stomach  should,  of  course,  be  empty,  and  the  same  precau- 
tions should  be  taken  as  for  general  anesthesia  (see  page  2).     Appre- 


68  .  LOCAL   ANESTHESIA 

hensive  anticipation  on  the  part  of  the  patient  should  be  prevented 
as  far  as  possible  by  reassurances  and  by  a  good  night's  sleep  before 
the  operation. 

Preliminary  medication  with  morphin  is  advisable  in  all  cases, 
where  the  operation  is  to  be  at  all  extensive,  unless  some  distinct 
contraindication  to  its  use  exists.  It  serves  a  threefold  purpose:  it 
allays  nervousness  on  the  part  of  the  patient  and  thus  removes  the 
psychic  element;  it  somewhat  deadens  sensibility;  and  it  is  the 
physiological  antidote  for  cocain  poisoning.  It  may  be  given  hy- 
podermically  in  the  dose  of  i/6  to  1/4  gr.  (0.0108  to  0.0162  gm.)  a 
half  hour  before  operation.  In  some  cases,  where  the  patient  is 
especially  nervous  or  unusual  difficulties  are  expected,  morphin 
1/4  gr.  (0.0162  gm.)  combined  with  i/ioo  gr.  (0.00065  gm.)  of 
hyoscin  may  be  administered  hypodermically  two  hours  before 
operation. 

The  Conduction  of  the  Operation. — It  may  not  be  out  of  place  at 
this  point  to  say  a  few  words  about  the  proper  conduction  of  an  opera- 
tion under  local  anesthesia.  The  successful  and  satisfactory  em- 
ployment of  this  method  of  anesthesia  depends  upon  an  intelligent 
appreciation  of  its  limitations,  upon  the  experience  and  skill  of  the 
operator,  and  upon  an  accurate  knowledge  of  the  sensory  nerve  supply 
in  an}'  given  region.  These  are  essential.  Much  also  depends  upon 
the  temperament  of  the  operator  and  upon  his  method  of  operating. 
For  this  reason,  with  some  operators,  the  use  of  local  anesthesia  will 
be  impossible;  with  others,  it  will  necessitate  a  radical  change  in  their 
operative  technic.  A  nervous  fidgety  operator,  in  a  hurry  to  get 
through  his  work,  will  never  find  much  to  encourage  him  in  attempts 
to  employ  local  anesthesia  in  major  surgery. 

It  is  important,  in  the  first  place,  to  make  the  patient  as  comfort- 
able as  possible  upon  the  operating-table.  Operations  under  local 
anesthesia  consume  considerable  time,  and  it  is  a  hardship  to  keep  a 
conscious  patient  upon  the  ordinary  hard-topped  operating-table  for 
an  hour  or  more.  Several  thicknesses  of  blanket,  an  air  mattress,  or 
a  layer  of  soft  pillows  placed  upon  the  table,  will  add  much  to  the 
patient's  comfort,  as  well  as  to  the  peace  of  mind  of  the  operator. 
The  patient  should  always  be  recumbent,  and  a  comfortable,  relaxed 
attitude  should  be  assumed,  with  the  arms  folded  over  the  chest  or 
clasped  above  the  head.  While  washing  the  patient  in  preparation 
for  the  operation,  it  should  be  borne  in  mind  that  he  is  conscious 
and  great  gentleness  should  be  employed  in  the  process.  Care 
should  also  be  taken  not  to  soak  the  patient  with  large  quantities  of 


LOCAL    AXESTHESLA.  69 

solution  and  leave  him  lying  in  a  chilly  pool  for  the  remainder  of  the 
operation. 

With  very  nervous  individuals,  it  is  \yell  to  keep  the  instruments 
covered  from  view  and  to  avoid  all  reference  to  knives,  scissors,  etc. 
In  fact,  strict  silence  should  be  enjoined  upon  all.  The  patient's 
mental  attitude  can  be  further  influenced  to  advantage  by  observing 
a  quiet  demeanor  in  the  operating-room,  by  the  avoidance  of  haste, 
and  by  a  most  careful  handling  of  the  tissues.  Clean-cut  dissection 
only  is  allowable  in  operations  under  local  anesthesia.  Rough  ma- 
nipulations, or  tearing  of  the  tissues,  or  unnecessary  pulling  with 
retractors  by  an  awkward  assistant  causes  pain  by  dragging  upon 
structures  outside  the  anesthetized  area  and  is  often  sufficient  to  cause 
restlessness  and  apprehension  on  the  part  of  the  patient,  a  state  of 
mind  which,  if  produced  in  the  early  part  of  an  operation,  rapidly 
changes  to  complete  demoralization,  and  renders  the  chances  of  com- 
pleting the  operation  without  the  aid  of  a  general  anesthetic  very 
smaU.  Rough  wiping  of  the  wound  is  likewise  to  be  avoided.  In 
fact,  in  every  move  and  step  the  aim  of  the  operator  should  be  extreme 
gentleness.  Xeglect  in  observing  these  small  and  apparently  trivial 
details  is  responsible  for  many  of  the  failures  with  local  anesthesia, 
and  often  results  in  condemnation  of  the  method,  though  the  fault 
lies  with  the  operator. 

THE  PRODUCTION  OF  LOCAL  ANESTHESIA  BY  COLD 

The  anesthetic  properties  of  intense  cold  have  long  been  recog- 
nized and  utilized  in  minor  surgery.  The  tissues  may  readily  be 
frozen  sufficiently  for  anesthetic  purposes  by  the  apphcation  of  sait- 
and  ice,  or  by  spraying  the  part  with 
some  rapidly  evaporating  chemical. 
such    as    ether,    rhigoline.    or   ethyl 

chlorid.     The  tissues  as  a  result  be-      ^ 

r      ,  1  ]     ,1  11         1      J        Fig.  40. — Ethvl  chlorid  spray  tube, 

come  first  red  and    then    blanched, 

and  a  superficial  anesthesia  is  produced,  which  persists  but  a  few 
minutes.  This  form  of  anesthesia  has  a  very  small  field  of  useful- 
ness, and  is  only  suitable  for  small  incisions  or  punctures;  even  in 
these  cases  the  method  is  open  to  the  objection  that  the  tissues  be- 
come so  hard  that  it  is  diflicult  to  cut  through  them  at  times,  and 
any  dissection  is  out  of  the  question.  Furthermore,  the  thawing 
out  process  is  attended  with  more  or  less  pain.  Freezing  often  lowers 
the  vitality  of  the  tissues  to  such  an  extent  that  sloughing  results; 


70  LOCAL   AXESTHESLV 

especially  is  this  so  when  applied  to  the  tissues  of  poorly  nourished 
individuals. 

Ethyl  chlorid  is  now  used  almost  exclusively  for  the  purpose  of 
freezing,  and  is  both  quick  and  effective.  It  is  obtained  in  glass  tubes 
with  one  end  drawn  out  to  a  line  point  and  furnished  with  a  spring 
tip  (Fig.  40)  or  with  a  screw  cap.  The  method  of  application  is 
extremely  simple.  The  tube  is  uncovered  and  held  inverted  in  the 
hand  at  a  distance  of  12  to  18  inches  (30  to  45  cm.)  from  the  surface  of 
the  skin.  Under  the  heating  influence  of  the  hand  the  liquid  is 
forced  out  of  the  container  upon  the  tissue  in  a  fine  jet  or  spray. 
Rapid  evaporation  occurs,  and,  in  about  thirty  seconds,  the  skin 
becomes  white  and  sufficiently  frozen  to  be  devoid  of  sensation. 

THE  SURFACE  APPLICATION  OF  ANESTHETIC  DRUGS 

Cocain  and  other  drugs  with  similar  anesthetic  action  may  be 
applied  to  mucous  surfaces  (i)  by  instillation,  as  in  the  eyes,  bladder, 
urethra,  etc.;  (2)  by  means  of  a  spray  or  atomizer,  as  in  the  mouth  or 
nose;  and  (3)  upon  swabs  or  compresses,  either  in  solution  or  in 
crystals.  Only  the  surface  of  the  mucous  membranes  is  anesthetized 
in  this  way,  but  a  number  of  operations  not  involving  the  deeper 
tissues,  such  as  the  removal  of  pol}-pi  or  small  tumors,  and  opening 
of  infections  may  thus  be  performed. 

For  operations  about  the  eye.  a  drop  or  two  of  a  2  to  4  per  cent, 
solution  of  cocain  is  instilled  into  the  eye  every  ten  minutes  until 
three  or  four  drops  have  been  given. 

Local  anesthesia  of  the  nasal  mucous  membrane  may  be  pro- 
duced by  applying  a  4  per  cent,  solution  of  cocain  upon  swabs  of 
cotton  directly  to  the  part  to  be  anesthetized.  Spraying  is  not 
so  desirable,  as  the  solution  is  Kable  to  ran  down  into  the  pharynx 
through  the  posterior  nares  and  produce  a  very  unpleasant 
sensation  in  the  throat,  and,  at  the  same  time,  the  amount  of 
solution  necessary  to  produce  anesthesia  being  larger,  the  danger 
of  poisoning  is  greater.  To  increase  the  efi'ectiveness  of  the 
cocain  and  obtain  a  bloodless  field  of  operation,  a  spray  of  a  i  to 
iCMDo  adrenalin  solution  may  be  employed  after  the  cocainization. 

In  the  larynx  cocain  may  be  applied  more  freely  without  danger 
than  is  the  case  when  it  is  applied  to  the  nasal  mucous  membrane. 
Small  quantities  of  a  10  per  cent,  solution  may  be  applied  by  means 
of  a  spray,  or,  better,  applied  directly  to  the  desired  spot  on  a  swab, 
with  the  aid  of  a  laryngeal  mirror. 


INFILTRATION   ANESTHESIA  7 1 

The  anterior  urethra  may  be  sufficiently  anesthetized  by  filling  it 
with  a  0.2  per  cent,  cocain  and  adrenalin  solution,  introduced  by 
means  of  a  urethral  syringe.  The  solution  should  be  confined  in  the 
urethra  for  at  least  fifteen  minutes,  by  holding  the  meatus  closed. 
The  posterior  urethra  may  be  anesthetized  by  instilling  into  it  a  few 
drops  of  a  I  per  cent,  cocain  and  adrenalin  solution  or  a  2  per  cent, 
novocain  adrenalin  solution  by  means  of  an  instillation  syringe  or 
through  a  soft  rubber  catheter. 

For  the  bladder,  a  o.i  per  cent,  cocain  and  adrenalin  solution  is 
sufficient.  Five  ounces  (150  c.c.)  of  such  a  solution  to  which  is  added 
twenty  drops  (1.25  c.c.)  of  adrenalin  is  slowly  introduced  warm  by 
means  of  a  catheter,  the  bladder  having  been  previously  irrigated. 
The  operator  should  then  wait  fifteen  to  twenty  minutes  for  the  drug 
to  take  effect. 

INFILTRATION  ANESTHESIA 

Infiltration  anesthesia  was  devised  by  Schleich  after  a  series  of 
careful  experiments  with  salt  solutions  of  different  strengths,  com- 
bined with  minute  quantities  of  morphin,  cocain,  and  carbolic  acid. 
From  his  work  has  been  evolved  the  weak  cocain  solution,  as  used  at 
the  present  time,  which  has  made  possible  the  safe  employment  of 
cocain  in  really  extensive  operations. 

By  infiltration  is  meant  the  production  of  analgesia  in  a  part  by 
edematization  of  the  tissues  with  weak  anesthetic  solutions.  The 
fluid  is  introduced  into  the  tissues,  carefully  avoiding  important  vas- 
cular structures,  without  particular  reference  to  the  nerve  trunks. 
The  resulting  anesthesia  is  partly  due  to  the  direct  action  of  the  drug 
upon  the  nerve  endings,  partly  to  the  pressure  of  the  fluid,  and  also  to 
the  interference  with  the  blood  supply.  The  anesthesia  may  be  in- 
creased and  indefinitely  prolonged  if  the  circulation  be  kept  stationary 
by  some  form  of  constriction  applied  to  the  part,  centrally  to  the  seat 
of  injection,  or  by  incorporating  in  the  fluid  infiltrated  vasoconstrictor 
drugs  like  adrenalin.  With  the  infiltration  method  of  anesthesia  it 
is  necessary  to  thoroughly  edematize  or  literally  pack  the  tissues  with 
the  anesthetic  fluid,  for,  without  this,  the  weak  solution  employed 
would  be  worthless. 

Apparatus. — For  the  purposes  of  ordinary  infiltration  the  6oTn, 
(4  c.c.)  or  the  10  c.c.  (2  1/2  dram)  sub-Q  syringe  is  very  satisfactory. 
This  syringe  has  a  solid  glass  barrel  and  glass  piston  with  asbestos 
packing,  and  can  be  readily  sterilized,  and  is  cheap.     Several  of  these 


72 


LOCAL   ANESTHESIA 


syringes  should  be  on  hand  for  the  operation,  and  are  to  be  kept  filled 
in  readiness,  so  that  the  infiltration  may  be  carried  on  rapidly  without 
waiting  to  recharge  the  same  syringe.  The  needles  should  be  sharp 
and  fine,  with  a  very  short  bevel,  and  they  should  fit  the  syringe  with- 
out any  leakage  at  the  joint.     It  will  be  convenient  to  have  a  short 


Fig.  41. — Apparatus  for  infiltration. — i,  Medicine  glasses  for  cocain  solutions; 
2,  ampule  of  sterile  cocain  and  salt  crystals;  3,  dropper  for  adrenalin;  4,  syringe 
armed  with  a  short  needle;  5,  long  fine  needle  for  deep  infiltration. 

needle,  i  inch  (2.5  cm.)  long,  for  skin  infiltration,  and  a  second  one, 
2  to  2  1/2  inches  (5  to  6  cm.)  long,  for  infiltration  of  the  deeper 
tissues. 

For  massive  infiltration  a  large  syringe  or  a  special  apparatus 


Fig.  42. — The  Matas  massive  infiltrator. 

which  will  allow  a  continuous  and  rapid  infiltration  of  the  tissues  is 
more  satisfactory.  The  ]Matas  infiltrator  (Fig.  42)  consists  of  a 
heavy  glass  graduated  receptacle  for  the  solution  with  an  air-tight 
screw  cap.  Into  this  cap  is  fitted  a  T-tube  with  two  stopcocks,  one 
for  the  introduction  of  air,  and  one  for  the  escape  of  the  fluid.     A 


INFILTRATION   ANESTHESIA 


73 


rubber  inflating  apparatus  is  attached  to  the  first  cock,  and  to  the 
other  is  a  needle  connected  by  a  suitable  length  of  hose.  The  reser- 
voir is  filled  about  three-fourths  full  and  is  then  charged  with  air, 
and  the  bulb  and  tubing  are  removed.  Infiltration  is  performed  by- 
inverting  the  apparatus  and  opening  the  outflow  stopcock.  Several 
needles  of  different  lengths,  shapes,  and  sizes  are  provided  with  this 
instrument.  The  author  uses  an  infiltrator  made  on  much  the  same 
principles  as  the  Matas  instrument. 
It  consists  of  a  long  graduated  glass 
cylinder  capable  of  holding  lo  ounces 
(300  c.c),  with  an  outlet  at  the  bot- 
tom and  a  rubber  stopper  fastened  in 
the  top  by  a  clamp.  A  small  glass 
tube  connected  with  an  inflating  bulb 
passes  through  this  stopper  (Fig.  43). 
The  reservoir  is  almost  filled  with  the 
solution,  leaving  about  one  quarter 
for  air  space,  and  the  instrument  is 
charged  with  sufficient  air  to  cause 
the  fluid  to  flow  through  the  needle 
in  a  strong  stream. 

Asepsis. — The  syringes,  needles, 
and  receptacles  in  which  the  solu- 
tions are  mixed  should  be  boiled  in 
pure  water  without  the  addition  of 
soda  or  other  alkali. 

Technic. — In  all  cases  where  an 
extensive  or  prolonged  operation  is 
contemplated  morphin,  gr.  1/4 
(0.0162  gm.),  should  be  given  hypo- 
dermically  half  an  hour  beforehand, 

unless  contraindicated.  For  the  skin  infiltration,  a  warm  0.2  per 
cent,  solution  of  cocain  and  adrenalin  or  a  i  per  cent,  novocain 
adrenalin  solution  in  normal  salt  solution  may  be  used.  The 
syringe  is  filled  with  solution  and  the  needle  is  shown  to  the  pa- 
tient with  an  explanation  of  just  what  is  intended  to  be  done.  This 
is  necessary  in  order  to  avoid  an  often  unexpected  shock  from  the 
first  prick  of  the  needle.  The  needle,  held  almost  parallel  to  the 
surface,  is  pushed  into  the  skin  just  beneath  the  epidermis — not 
beneath  the  skin — so  as  to  anesthetize  the  sensitive  end  organs.  If 
the  needle  lies  properly,  its  point  will  be  almost  visible  immediatcl}' 


Fig.  43. — The    author's   apparatus 
for  massive  infiltration. 


74 


LOCAL   ANESTHESIA 


below  the  skin  surface.  A  few  drops  of  solution  are  injected  and  the 
skin  becomes  blanched  and  raised  into  a  wheal  about  the  size  of  a 
ten-cent  piece  (Fig.  44).  The  needle  is  then  reinserted  into  the 
edge  of  the  wheal  and  more  solution  injected  in  the  same  manner, 


Fig.  44. — Showing  the  method  of  infiltrating  the  skin.  The  needle  is  inserted 
in  such  a  way  that,  with  the  injection  of  a  few  drops  of  solution,  a  wheal  the  size 
of  a  ten-cent  piece  is  produced. 

until  the  entire  line  of  the  proposed  incision  is  one  continuous  wheal 
(Fig.  45).  In  this  way,  only  the  first  prick  of  the  needle  is  felt  by 
the  patient. 

The  subcutaneous  tissue,  which  is  in  itself  insensitive  but  carries 
sensitive  nerve  trunks  and  blood-vessels,  is  next  very   thoroughly 


Fig.  45. — Showing  the  reinsertion  of  the  needle  into  the  edge  of  the  wheal. 

infiltrated,  using  a  longer  and  somewhat  larger  needle.  For  this 
purpose  cocain  and  adrenalin  in  a  i  to  1000  solution  for  ordinary 
cases  and  in  a  i  to  3000  to  i  to  loooo  solution  for  massive  infiltration 
of  large  areas  or  a  1/4  to  1/8  per  cent,  novocain  adrenalin  solution  may 


INFILTRATION    ANESTHESIA 


75 


be  used.  The  needle  is  inserted  into  the  line  of  the  skin  cocainiza- 
tion,  and  the  solution  is  injected  in  all  directions  from  this  point,  so 
as  to  practically  surround  the  area  of  proposed  incision  with  anesthetic 
solution.  Special  care  is  taken  to  thoroughly  infiltrate  known 
sensitive  regions,  as,  for  instance,  in  the  operation  for  inguinal  hernia 
about  the  external  ring  where  the  main  nerve  trunks  break  up  into 


Fig.  46. — Showing  the  directions  in  which  the  needle  should  be  inserted  in  massive 
infiltration  of  deep  structures. 

their  terminal  filaments.  In  the  case  of  an  operation  upon  a  cir- 
cumscribed growth,  the  infiltration  is  carried  out  in  such  a  way  as  to 
completely  encircle  the  diseased  area  and  isolate  it  from  nerve  com- 
munication with  the  surrounding  parts.  In  like  manner  fascia„ 
muscles,  down  to  or  including  the  periosteum,  may  be  infiltrated  in 
a  mass,  after  the  method  of  Matas  (Fig.  46),  or  each  structure  sepa- 


FiG.  47. — Showing  the  application  of  a  constricting  band  to  the  finger  in  order  to 
prolong  and  intensify  the  anesthesia. 

lately  as  it  is  exposed  during  the  course  of  the  operation.  Muscle, 
tendon,  bone,  and  cartilage  have  no  sensation,  but  their  coverings 
are  extremely  sensitive;  hence  particular  care  must  be  taken  to  in- 
filtrate fascia,  muscle,  and  tendon  sheaths,  periosteum,  and  joint 
capsules,  and  when  operating  upon  joints  to  anesthetize  the  synovial 
membranes  by  a  preliminary  instillation  of  weak  cocain  solution 


7 6  LOCAL    ANESTHESL\ 

into  the  joint  before  operation.  With  proper  infiltration  the  whole 
field  is  thoroughly  edematized  and  is  changed  into  a  tumor-like  mass 
that  is  perfectly  anesthetic. 

While  the  infiltration  method  is  carried  out  without  any  attempt 
to  specially  anesthetize  nerve  trunjis,  the  larger  ones  should  never- 
theless be  injected  after  the  method  to  be  described  whenever  they 
are  encountered  during  the  operation. 

Upon  an  extremity,  more  complete  and  prolonged  anesthesia  may 
be  obtained  if.  after  infiltration,  stasis  of  the  circulation  is  produced 
bv  means  of  elastic  constriction  applied  centrally  to  the  seat  of  in- 
filtration (Fig.  47).  In  such  a  case,  where  large  quantities  of  solu- 
tion are  used  and  remain  in  the  tissues  when  the  operation  is  com- 
pleted, it  is  a  wise  precaution  to  loosen  the  constriction  gradually 
and  intermittently,  so  as  not  to  rapidly  flood  the  system  with  a  large 
volume  of  cocain  solution. 

ENDO-  AND  PERINEURAL  INFILTRATION 

The  discovery  that  injections  of  cocain.and  similar  analgesics  into 
the  tissues  surrounding  a  nerve  (perineural  infiltration)  or  directly 
into  it  (endoneural  infiltration)  will  efi"ectually  block  the  particular 
nerve  and  produce  anesthesia  in  the  entire  area  of  its  distribution  has 
ftiade  possible  many  operations  of  magnitude,  such  as  those  for  hernia, 
amputations,  etc.  Successful  nerve  blocking  presupposes  an  accu- 
rate knowledge  of  the  course  and  distribution  of  the  sensory  nerves. 
It  may  be  performed  at  a  distance  from  the  seat  of  operation  by  in- 
jecting the  cocain  solution  around  the  nerve,  or  by  cutting  down  and 
exposing  the  nerve  before  injection;  or  the  blocking  may  be 
performed  by  separately  injecting  each  nerve  as  it  is  exposed  during 
the  course  of  the  operation.  The  action  of  the  anesthetic  is  in- 
tensified and  indefinitely  prolonged  by  arresting  the  circulation  in 
the  injected  and  anesthetized  nerve  trunks  by  means  of  elastic  con- 
striction, as  already  spoken  of  under  infiltration,  and  to  a  lesser 
degree  by  the  addition  of  adrenahn  to  the  analgesic  solution. 

The  perineural  method  of  infiltration  is  more  suited  to  regions  sup- 
plied by  the  smaller  superficial  nerv'es  and  to  the  smaller  extremities, 
as  the  fingers  and  toes.  For  anesthetizing  the  large  nerve  trunks 
with  thick  sheaths,  direct  injection  of  the  nerv^es  as  they  are  exposed 
in  the  field  of  operation,  or  at  some  point  along  the  course  of  the  nerve 
central  to  the  seat  of  operation,  will  give  more  certain  results.  When 
a  region  is  supplied  by  several  nerves,  each  will  have  to  be  separately 
isolated  and  blocked. 


ENDO-    AND    PERINEURAL   INFILTRATION 


77 


Apparatus. — The  ordinary  60T11  (4  c.c.)  or  10  c.c.  (2  1/2  dr.) 
"Sub-Q"  syringe,  with  a  fairly  long  needle  will  be  found  most 
satisfactory. 

Asepsis. — The  needles,  syringes,  and  solution  glasses  are  sterilized 
by  boiling  in  pure  water  without  the  addition  of  soda  or  other  alkali. 

Technic. — In  the  perineural  method  of  infiltration  the  analgesic 
solution  is  injected  in  such  a  way  as  to  surround  the  nerve  trunk  or 
"envelop  the  nerve  in  an  anesthetic  atmosphere,"  as  Matas  expresses 
it.  A  spot  in  the  skin  from  which  the  nerve  can  be  reached  with  the 
hypodermic  needle  is  infiltrated  as  already  described,  and  through 
this  area  the  needle  is  inserted  toward  the  known  location  of  the  par- 
ticular nerve  to  be  anesthetized.  The  syringe  is  charged  with  a  0.2 
per  cent,  solution  of  cocain  and  adrenalin  or  a  i  per  cent,  novocain 


Fig.  48. — Method  of  infiltrating  a  large  nerve  trunk.  The  anesthetic  solution 
should  be  injected  into  the  nerve  in  all  directions  so  that  the  entire  nerve  is  ren- 
dered anesthetic  below  the  point  of  injection. 


adrenahn  solution  and  from  15  to  20  drops  are  injected  into  the 
tissues  surrounding  the  nerve.  The  solution  is  allowed  to  become 
diffused,  and  then,  if  the  nerve  be  in  an  extremity,  the  part  is  ex- 
sanguinated by  elevation  and  an  elastic  constriction  is  apphed  cen- 
trally to  intensify  and  prolong  the  anesthesia.  In  a  few  moments  the 
entire  region  supplied  by  the  blocked  nerve  becomes  insensible.  It 
may  happen  that,  in  regions  where  constriction  is  inapplicable,  the 
anesthesia  may  not  be  sufficiently  lasting  for  a  prolonged  operation, 
and  it  will  be  necessary  to  repeat  the  injection  more  than  once  to 
maintain  the  anesthesia. 

By  the  endoneural  method,  if  the  nerves  are  injected  in  the  field 
of  operation,  the  technic  is  very  simple,  the  individual  nerves  being 
infiltrated  with  a  few  drops  of  a  0.5  per  cent,  solution  of  cocain  or  a  2 
per  cent,  solution  of  novocain  as  they  are  exposed.     When  the  injec- 


78  LOCAL   ANESTHESIA 

tion  is  made  at  a  point  distal  to  the  seat  of  operation  the  nerve  is 
first  exposed  by  dissection  under  infiltration  anesthesia  and  is  then 
thoroughly  infiltrated,  the  fluid  being  injected  into  all  portions  of 
the  nerve  so  that  an  entire  transverse  section  is  thoroughly 
blocked  (Fig.  48).  Other  nerves  supplying  the  region  of  operation 
are  similarly  dealt  with.  The  part  is  then  exsanguinated  by  eleva- 
tion and  an  elastic  constriction  is  applied  centrally  to  the  point  of 
injection.  In  a  short  time  all  sensation  below  the  seat  of  injection 
becomes  benumbed,  and  operations  of  any  magnitude  may  be 
performed. 

Practical  Application  of  Infiltration,  Endo=  and  Perineural 
Methods  of  Anesthesia  to  Special  Localities. — The  methods  of 
locally  anesthetizing  a  part  just  described  all  have  their  special  indi- 
cations. The  operator  should  not  employ  one  method  to  the  exclu- 
sion of  the  others,  but  should  make  his  selection  so  as  to  successfully 
meet  the  indications  in  a  particular  case.  In  a  certain  proportion  of 
the  cases  infiltration  alone  will  sufiice;  in  others,  the  nerve  blocking 
can  be  used  to  better  advantage;  but  in  the  majority  of  extensive 
operations  it  will  be  found  that  a  combination  of  infiltration  with 
endoneural  injections  is  essential  to  a  successful  anesthesia  in  a  given 
region.  A  brief  description  of  the  application  of  these  methods  to 
different  regions  of  the  body  will  furnish  some  idea  as  to  the  scope  and 
capabilities  of  each. 

The  Head. — Operations  upon  the  scalp,  such  as  wound  suture, 
the  removal  of  tumors,  cysts,  etc.,  and  even  procedures  requiring 
incision  of  the  periosteum  and  opening  into  the  brain,  may  be  per- 
formed painlessly  under  a  combination  of  infiltration  and  perineural 
anesthesia.  An  accurate  knowledge  of  the  nerve  supply  of  the  region 
is  essential,  however. 

Briefly,  the  scalp  has  the  following  nerve  supply  (Fig.  49).  The 
small  occipital  and  great  occipital  nerves  supply  the  posterior  part 
of  the  scalp  as  far  forward  as  the  vertex.  The  great  auricular  nerve 
suppHes  the  mastoid  region,  as  does  also  the  small  occipital.  The 
parietal  portion  of  the  scalp  receives  its  supply  from  the  auriculo- 
temporal and  a  branch  of  the  temporomalar.  The  supratrochlear 
branch  of  the  frontal  nerve  suppHes  the  integument  of  the  lower  part 
of  the  forehead  on  either  side  of  the  median  line.  The  supraorbital 
supplies  the  cranium  over  the  frontal  and  parietal  bones.  Blocking 
these  nerves  by  cross  strips  of  infiltration  at  the  points  where  they 
penetrate  the  muscular  fascia  and  become  subcutaneous  (Fig.  50), 
or  performing  a  thorough  circumscribed  infiltration  around  the  area 


EXDO-    AND    PERINEURAL    IXEILTRATION 


79 


of  operation,  with  infiltration  of  the  periosteum,  if  necessary,  renders 
many  cases  amenable  to  local  measures  which  are  now  performed 
under  general  narcosis.  Constriction  by  means  of  a  rubber  tourni- 
quet passed  around  the  forehead  above  the  ears  and  over  the  occipital 
protuberance  will  be  found  most  useful  as  an  aid  to  anesthesia. 

About  the  lips,  chin,  nose,  cheeks,  tongue,  mouth,  and  lower  jaw 
local  means  of  anesthesia  are  often  quite  sufficient.  Blocking  of  the 
mental  nerve  as  it  emerges  from  the  mental  foramen  will  render 
insensitive  the  region  of  the  chin  and  the  skin  and  mucous  membrane 


Fig.  49.  Fig.  50. 

Fig.  49. — The  superficial  ner\'es  of  the  scalp  and  face,  i,  Supratrochlear  nerve; 
2,  supraorbital  nerve;  3,  temporal  branch  of  the  temporomalar  nerve;  4,  auriculo- 
temporal nerve;  5,  great  auricular  nerve;  6,  small  occipital  nerve;  7,  great  occipi- 
tal nerve;  8,  infratrochlear  nerve;  9,  infraorbital  nerve;  10,  nasal  nerve;  11, 
mental  nerve. 

Fig.  50. — Showing  the  area  of  anesthesia  after  blocking  the  supratrochlear, 
supraorbital,  and  mental  nerves.     The  dots  indicate  the  points  for  infiltration. 


of  the  lower  lip  of  the  same  side  (see  Fig.  50).  In  like  manner  the 
upper  lip  may  be  anesthetized  by  blocking  of  the  infraorbital 
nerves.  The  inferior  dental  nerve  is  readily  reached  for  blocking  as 
it  enters  the  inferior  dental  foramen  at  the  outer  side  of  the  spine  of 
Spix.  This  point  lies  near  the  median  line  of  the  internal  surface  of 
the  ramus  of  the  jaw  about  haK  an  inch  (i  cm.)  above  the  upper  surface 
of  the  last  molar  tooth  (Fig.  51).  The  lower  jaw  may  be  thus  anes- 
thetized and  teeth  may  be  painlessly  extracted.     The  Ungual  nerve 


8o 


LOCAL   ANESTHESIA 


may  be  perineurally  infiltrated  at  about  the  same  point,  as  it  lies 
close  to  the  inferior  dental.  The  floor  of  the  mouth  and  the  tongue 
are  thus  rendered  insensitive,  and  quite  extensive  operations  may 
be  performed.  Infiltration  alone,  however,  is  often  sufl5cient  in  the 
smaller  operations  about  the  lips  and  mouth. 

Blocking  of  the  branches  of  the  trifacial  nerve  at  their  points  of 
exit  from  the  base  of  the  skull  gives  a  wide  area  of  anesthesia  and 
permits  the  painless  performance  of  very  extensive  operations  in  the 
region  supplied  by  these  nerves,  such  as  removal  of  the  tongue, 
resection  of  the  upper  and  lower  jaws,  operations  upon  the  orbit, 
etc.     As  early  as  1900  Matas  reported  a  resection  of  both  upper 


Fig.  51. — Showing  the  method  of  blocking  the  inferior  dental  nerve. 


jaws  after  cocainization  of  the  second  division  of  the  fifth  nerve. 
More  recently  Braun  and  others  have  reported  extensive  operations 
performed  by  similar  methods.  The  technic  of  reaching  these  nerves 
is  similar  to  that  employed  by  Schlosser,  Patrick,  and  others  in  the 
use  of  alcoholic  injections  for  trifacial  neuralgia  (see  page  197). 

The  Neck. — Operations  upon  the  neck  for  the  removal  of  benign 
growths,  isolated  freely  movable  glands,  or  for  the  ligation  of  vessels 
are  performed  by  infiltration  of  the  lines  of  incision  combined  with 
massive  infiltration  of  the  surrounding  tissues.  As  already  men- 
tioned, thyroidectomy  and  tracheotomy  may  be  carried  out  by 
following  the  same  principles.     In  superficial  operations  upon  the 


EXDO-    AXD    PERINEURAL    IXFILTRATION  8 1 

anterior  and  posterior  triangles,  perineural  blocking  by  a  strip  of 
infiltration,  or  direct  injection  of  the  superficial  branches  of  the  cervi- 
cal plexus  as  they  escape  from  the  posterior  border  of  the  sterno- 
mastoid  muscle  at  or  about  its  middle  will  be  of  great  aid  (Fig.  53). 
Operations  upon  the  larynx  may  be  performed  under  infiltration 
anesthesia  combined  T\ath  blocking  of  the  superior  laryngeal  nerve 
at  the  tip  of  the  greater  cornu  of  the  hyoid  bone. 


Fig.  52.  Fig.  53. 

Fig.  52. — The  superficial  cervical  plexus.  The  dotted  lines  indicate  the  course 
of  the  stemomastoid  muscle. 

Fig.  53. — Showing  the  area  of  anesthesia  after  blocking  the  superficial  cervical 
plexus.     The  dots  indicate  the  points  for  infiltration. 

The  Thorax. — Exploratory  punctures,  aspiration  of  the  peri- 
cardium and  pleura,  rib  resection  for  empyema,  and  the  removal  of 
benign  growths  from  the  breast  may  all  be  satisfactorily  performed 
under  infiltration.  In  the  operation  of  rib  resection  the  infiltration 
should  be  carried  out  layer  by  layer,  including  the  periosteum. 
Perineural  blocking  of  the  intercostal  nerves  as  they  pass  between  the 
intercostal  muscles  in  the  upper  portion  of  the  intercostal  space,  or 
endoneural  injection  of  each  nerve  as  it  is  exposed,  will  assist  in  ren- 
dering the  operation  painless  where  more  than  one  rib  is  to  be  re- 
sected. For  a  perineural  injection  the  needle  is  inserted  close  to 
the  lower  margin  of  the  rib  about  one  and  one-fifth  inches  (3  cm.) 
from  the  median  line  and  is  pushed  in  for  a  distance  of  i  ^/^  to  2  in. 
(4  to  5  cm.)  when  it  strikes  the  bone.  An  attempt  is  next  made  to 
guide  the  needle  below  the  lower  edge  of  the  rib.  The  injection  is 
6 


82  LOCAL   ANESTHESIA 

then  commenced  and  is  continued  as  the  needle  is  carried  inward 
and  toward  the  median  Hne  well  into  the  subcostal  angle  for  a  distance 
of  1/4  to  1/2  an  inch  (6  to  12  mm.).  As  many  of  the  other  inter- 
costal nerves  as  may  be  necessary  are  similarly  blocked.  After  the 
periosteum  over  the  rib  is  incised  and  reflected,  the  rib  may  be  ex- 
sected  without  pain.  The  parietal  pleura,  like  the  peritoneum,  is 
very  sensitive  and  requires  infiltration  before  incision. 

The  Upper  Extremity. — Almost  any  operation  may  be  performed 
in  this  region  under  a  skilful  use  of  local  anesthesia.  The  brachial 
plexus  may  be  anesthetized  by  exposing  it  under  infiltration  anes- 
thesia above  the  clavicle  (Fig.  54)  and  blocking  each  branch  sepa- 
rately by  direct  injection  with  a  0.5  per  cent,  solution  of  cocain  or  a 


Fig.  54. — Exposure  of  the  brachial  plexus  for  infiltration,  i,  External  jugular 
vein;  2,  transversalis  colli  artery;  3,  scalenus  anticus  muscle;  4,  fifth  cervical 
root;  5,  sixth  cervical  root;  6,  seventh  cervical  root;  7,  clavicle. 

2  per  cent,  solution  of  novocain,  or  by  a  perineural  injection  after  the 
method  of  Kulenkampff.  His  technic  is  as  follows:  The  patient  is 
placed  in  the  sitting  position  and  the  subclavian  artery  is  located  by 
palpation.  This  is  usually  at  a  point  where,  if  the  external  jugular 
vein  were  extended,  it  would  strike  the  clavicle.  The  needle  is 
inserted  just  outside  this  point  immediately  above  the  clavicle  in 
an  obhque  direction  slightly  back  and  downward  in  a  line  which,  if 
carried  back,  would  strike  the  spines  of  the  2d  or  3d  dorsal  vertebra. 
At  a  distance  of  about  i  1/5  inches  (3  cm.)  the  needle  should  reach 
the  nerve  trunks.  Paresthesia  throughout  the  arm  and  motor  phe- 
nomena indicate  when  this  has  been  accomphshed.^  If  the  needle 
strikes  the  first  rib  it  has  been  introduced  too  far.     Kulenkampft"  in- 

1  Injury  to  the  phrenic  nerve  with  embarrassed  respiration  and  diminished 
breath  sounds  has  been  reported  following  perineural  injection  of  the  brachial  plexus, 
so  that  care  should  be  taken  to  determine  the  presence  of  paresthesia  before 
making  the  injection  and  not  to  anesthetize  both  sides  at  the  same  time. 


ENDO-   AND   PERINEURAL   INFILTRATION 


83 


jects  2  1/2  drams  (10  c.c.)  of  a  2  per  cent,  solution  of  novocain  and 
adrenalin.  In  10  to  30  minutes  all  sensation  in  the  area  below  the 
point  of  injection  is  destroyed,  and  amputations  or  other  operations 
may  be  performed  at  any  level  below  the  seat  of  injection.  In  shoul- 
der-girdle amputations,  however,  infiltration  of  the  hnes  of  incision 
also  should  be  performed  in  order  to  block  small  branches  from  the 
cervical  plexus,  i.e.,  the  supraacromial  and  suprascapular  nerves. 

Operations  upon  the  forearm  require  blocking  of  the  median,  ul- 
nar, and  musculospiral  nerves.  This  may  be  accomplished  by  block- 
ing the  brachial  plexus  as  already  described,  by  directly  injecting  all 
three  nerves  after  exposure  under  infiltration  anesthesia  in  the  upper 


Fig. 


Fig.  56. 


Fig.  55. — -Exposure  of  the  musculospiral  and  median  nerves  at  the  elbow. 
Musculospiral  nerve;  2,  median  nerve. 

Fig.  56. — Exposure  of  the  ulnar  nerve  just  aJ)Ove  the  internal  condyle. 


portion  of  the  arm,  or  by  separately  exposing  and  blocking  each  nerve 
just  above  the  elbow.  In  following  the  latter  method,  the  median 
nerve  is  exposed  by  an  incision  across  the  elbow  to  the  inner  side  of 
the  biceps  muscle,  the  brachial  artery  lying  jast  external  to  it;  the 
ulnar,  in  the  groove  between  the  internal  condyle  and  the  olecranon; 
and  the  musculospiral,  between  the  biceps  tendon  and  the  supinator 
longus  muscle.  Blocking  each  nerve  with  a  0.5  per  cent,  solution  of 
cocain  or  a  2  per  cent,  solution  of  novocain  produces  complete  in- 
sensibility of  the  extremity  below  the  point  of  injection  excepting 
the  skin  and  subcutaneous  tissues  of  the  upper  central  portion  of  the 
forearm,  supplied  by  the  musculocutaneous  and  internal  cutaneous 


84 


LOCAL    ANESTHESIA 


nerves.  A  circular  area  of  subcutaneous  infiltration  at  the  elbow, 
however,  as  advised  by  ^Matas,  abolishes  any  remaining  sensibility 
in  this  region  (Fig.  57). 

Just  above  the  wrist,  the  median,  ulnar,  and  radial  nerves  are 
available  for  perineural  injection.     The  median  is  reached  by  intro- 


Fic.  57. — Showing  the  method  of  anesthetizing  the  small  superficial  nerves  by  cir- 
cular strips  of  subcutaneous  infiltration. 

ducing  the  needle  to  the  ulnar  side  of  the  tendon  of  the  palmaris 
longus  and  inserting  it  obUquely  for  a  distance  of  1/2  to  3/4  inch 
(i  to  2  cm.)  in  the  direction  of  the  radius.  The  ulnar  nerve  may  be 
anesthetized  perineurally  a  little  above  the  head  of  the  ulna  by  insert- 


FiG.  58. — Cross-section  of  the  forearm  above  the  wrist  showing  the  direction 
of  the  needle  for  perineural  infiltration  of  the  ulnar  and  median  nerves.  (After 
Braun.)  i,  Interosseousnerve;  2,  radial  nerve;  3,  radial  artery;  4,  median  nerve; 
5,  ulnar  ner\^e;  6,  areas  of  skin  infiltration;  7,  flexor  carpi  ulnaris  tendon;  8  pal- 
maris longus  tendon;  9,  flexor  carpi  radialis  tendon. 

ing  the  needle  to  a  depth  of  about  4/5  inch  (2  cm.)  between  the  ulna 
and  the  tendon  of  the  flexor  carpi  ulnaris.  The  radial  nerve  and  its 
branches  are  best  caught  by  a  cross  strip  of  subcutaneous  infiltra- 
tion just  above  the  styloid  process  of  the  radius  (Fig.  58).  Perineural 
injection  alone  for  operations  upon  the  wrist  is  not  satisfactory,  as 


ENDO-   AND    PERINEURAL   INFILTRATION 


85 


this  region  is  also  supplied  by  small  branches  given  off  from  these 
nerves  higher  up.  A  circular  strip  of  subcutaneous  infiltration  above 
the  wrist,  however,  will  render  the  anesthesia  complete  (see  Fig.  57). 


Fig.  59. — Points  for  inserting  the  needle  in  perineural  infiltration  of  the  digital 

nerves. 

In  thin  individuals,  massive  circular  infiltration  alone  is  generally 
sufficient  to  produce  anesthesia  below  the  site  of  injection. 

Anesthesia  of  the  fingers  is  obtained  by  infiltrating  two  points  in 
the  skin  on  the  dorsal  surface  near  the  base  of  each  finger  (Fig.  59). 


Fig.  60. — Cross-section  of  the  finger  showing  the  direction  of  the  needle  for 
perineural  infiltration  of  the  digital  nerves.  (After  Braun.)  i,  Extensor  tendons; 
2,  bone;  3,  flexor  tendons;  4,  areas  of  skin  infiltration. 

Through  these  points  the  needle  is  inserted  toward  each  of  the  four 
digital  nerves,  and  the  anesthetic  solution  injected  (Fig.  60).  All 
nerve  communication  is  thus  blocked  and  the  finger  may  be  incised, 
amputated,  etc.,  without  pain.     By  injecting  in  the  known  location 


86  LOCAL   ANESTHESIA 

of  the  digital  nerves  as  they  pass  between  the  metacarpal  bones,  the 
bases  of  the  fingers  and  even  the  metacarpals  may  be  anesthetized. 

The  Abdomen. — The  abdomen  may  be  opened  in  any  region  by 
simple  infiltration,  combined  with  endoneural  injection  of  nerves  as 
they  are  exposed.  The  skin,  the  subcutaneous  tissues,  the  fasciae, 
the  muscular  layers,  and  the  peritoneum  should  be  separately  in- 
filtrated, layer  by  layer.  More  perfect  anesthesia  may  be  obtained 
by  combining  with  the  infiltration  a  paravertebral  injection  of  the 
nerves  supplying  the  field  of  operation  after  the  method  of  Kappis. 
For  work  about  the  kidney  or  upper  abdomen  the  last  five  thoracic 
and  upper  two  lumbar  nerves  should  be  blocked.  The  technic  is 
as  follows:  The  needle  is  inserted  about  i  2/5  in.  (3.5  cm.)  from  the 
median  hne  on  a  level  with  the  lower  border  of  the  rib  and  is  inserted 
for  a  distance  of  i  3/5  to  2  in.  (4  to  5  cm.)  when  the  bone  should  be 
reached.  The  needle  is  then  made  to  pass  beneath  the  lower  border 
of  the  rib  and  the  injection  is  begun.  The  solution  is  slowly  injected 
while  the  needle  is  pushed  onward  for  a  distance  of  1/4  to  1/2  in. 
(6  to  12  m.m.)  slightly  toward  the  median  line  into  the  subcostal 
angle.  The  same  method  is  employed  for  the  lumbar  nerves,  the 
transverse  processes  of  the  vertebrae  being  the  guides  instead  of  the 
ribs.  The  limitations  of  local  anesthesia  in  abdominal  surgery  have 
already  been  considered  (page  62)  and  will  not  be  reiterated  here. 

Hernia. — While  operations  for  hernia  of  any  variety  may  be 
carried  out  under  local  anesthesia,  the  inguinal  will  be  found  espe- 
cially suited  to  this  method  of  anesthesia,  the  umbilical  and 
femoral  varieties  less  so. 

For  inguinal  hernia  a  combination  of  infiltration  and  endoneural 
injection  is  possible  on  account  of  the  anatomical  arrangement  of  the 
inguinal  region,  which  is  supplied  by  three  fairly  large  nerve  trunks 
having  a  rather  constant  course — namely,  the  iliohypogastric,  the 
iHoinguinal,  and  the  genitocrural.  The  iliohypogastric  will  be  found 
in  the  upper  angle  of  the  hernial  incision  after  reflecting  the  aponeu- 
rosis of  the  external  oblique,  usually  running  downward  and  inward 
on  a  line  drawn  from  about  the  anterior-superior  spine  to  a  point 
an  inch  (2.5  cm.)  above  the  external  ring.  The  ilioinguinal  will 
usually  be  found  in  the  line  of  incision  just  beneath  the  aponeurosis 
of  the  external  oblique,  and  on  a  lower  level  than  the  iliohypogastric, 
running  downward  in  the  long  axis  of  the  hernia  (Fig.  61).  It  may 
even  lie  as  far  out  as  Poupart's  ligament.  This  nerve  is  often  smaller 
than  the  iliohypogastric,  and  in  some  cases  it  may  be  absent,  in  which 
event  its  place  is  taken  by  the  genitocrural.     The  genitocrural  will  be 


ENDO-    AND    PERINEURAL    INFILTRATION 


87 


found  after  reflecting  the  aponeurosis  of  the  external  oblique  lying 
among  the  structures  of  the  cord,  and  frequently  it  lies  behind  the 
cord.  Infiltration  anesthesia  is  employed  until  the  aponeurosis  of 
the  external  obhque  is  reflected,  when  the  above  nerves  are  separately 
blocked.  In  performing  the  infiltration,  special  care  should  be  taken 
to  inject  plenty  of  solution  in  the  region  of  the  external  ring  where 
the  nerves  break  up  into  their  terminal  filaments.  After  the  nerves 
are  properly  blocked,  the  remainder  of  the  operation  may  be  pain- 
lessly performed  without  the  use  of  additional  anesthesia,  though  it 
is  better  to  infiltrate  about  the  neck  of  the  sac  before  ligating  and 
removing  that  structure.  Omentum  may  be  amputated,  adhesions 
within  the  sac  separated,  and  gut  resected  if  necessary,  without  pain. 


Fig.  61. — Showing  the  nerve  supply  of  the  inguinal  region.  (After  Gushing.) 
I,  Iliohypogastric  nerve;  2,  ilioinguinal  nerve;  3,  conjoined  tendon;  4,  cremaster 
muscle;  5,  aponeurosis  of  the  external  oblique  incised  and  edges  reflected. 


Femoral  hernia  may  be  operated  on  under  simple  infiltration  of 
the  skin,  subcutaneous  tissues,  and  sac;  or,  preferably,  by  a  combi- 
nation of  infiltration  and  endoneural  injection.  If  this  latter  method 
is  employed,  the  incision  is  placed  so  as  to  expose  in  addition  the 
external  abdominal  ring.  The  aponeurosis  of  the  external  obhque 
is  thus  exposed  and  is  incised  for  a  short  distance,  so  that  the  ilio- 
inguinal and  genitocrural  nerves  may  be  identified  and  injected. 
Blocking  of  these  nerves,  combined  with  infiltration,  renders  the 
field  of  operation  more  nearly  anesthetic  than  infiltration  alone. 

In  operations  for  umbilical  and  ventral  hernias,  the  infiltration 


88 


LOCAL    ANESTHESIA 


method  is  employed.  The  structures  are  separately  injected,  as 
would  be  done  for  an  abdominal  operation,  taking  special  care  to 
thoroughly  infiltrate  about  the  neck  of  the  sac. 


Fig.  62. — Showing  the  method  of  infiltrating  about  the  cord  in  operations  upon 

the  testicle. 

The  Scrotum. — Any  of  the  operations  about  the  scrotum  and 
testicles,  such  as  those  for  varicocele,  hydrocele,  castration,  etc., 
may  be  carried  out  by  perineural  injection  around  the  cord  as  it 
escapes  from  the  external  ring  (Fig.  62),  combined  with  infiltration 
along  the  site  of  incision. 


i 


Fig.  63. — Points  for  injection  in  infiltration  about  the  anus. 

Penis  and  Urethra. — Circumcision  may  be  performed  by  infiltrat- 
ing the  skin  and  mucous  membranes  along  the  hues  of  proposed  in- 
cision, being  careful  to  infiltrate  the  frenum  thoroughly.     More  ex- 


ENDO-    AND    PERINEURAL    INEILTRATION  89 

tensive  operations  upon  the  pendulus  portion  may  be  performed  by 
subcutaneous  infiltration  of  a  ring  about  the  base  of  the  penis,  care- 
fully injecting  the  solution  around  each  of  the  dorsal  nerves.  Exter- 
nal urethrotomy  may  be  performed  under  infiltration  combined 
with  topical  anesthesia  of  the  mucous  membrane  (see  page  71). 

Rectum  and  Anus. — The  limitations  of  local  anesthesia  in  rectal 
operations  have  been  previously  pointed  out.  For  the  removal  of 
external  hemorrhoids,  skin  tabs,  etc.,  injecting  a  small  amount  of 
anesthetic  solution  into  the  base  of  the  growth  is  sufficient.  When 
it  is  necessary  to  stretch  the  sphincter,  anesthesia  may  be  obtained 
in  the  following  manner:  Four  wheals  are  made  in  the  skin — in 
front,  behind,  and  at  the  sides  (Fig.  63) — and  through  these  points 
the  hypodermic  needle,  guided  by  a  finger  in  the  rectum,  is  carried 
up  along  the  bowel  and  the  sphincter  is  thoroughly   infiltrated. 

Lower  Extremity.— Blocking  of  the  anterior  crural,  the  external 
cutaneous,  and  the  sciatic  nerves,  combined  with  a  circular  strip  of 
subcutaneous  infiltration,  completely  blocks  all  sensation  in  the  lower 
extremity  below  the  level  of  the  "block,"  and  amputations  can  thus 
be  performed  as  high  as  the  lower  and  middle  thirds  of  the  thigh. 
Above  this  point,  however,  the  nerve  supply  is  complicated  and  it 
will  be  necessary  to  massively  infiltrate  along  the  line  of  incision  as 
well  as  to  "block"  the  nerve  trunks  already  mentioned.  The  exter- 
nal cutaneous  nerve  may  be  reached  for  injection  by  an  incision  so 
placed  as  to  expose  the  nerve  as  it  emerges  from  under  the  anterior 
superior  spine  (Fig.  64),  or  it  may  be  blocked  by  a  perineural  injection, 
the  needle  being  inserted  just  to  the  inner  side  of  the  anterior  superior 
spine.  Skin  grafting  may  be  readily  performed  by  blocking  the  nerve 
after  the  manner  just  described  and  taking  the  grafts  from  the  outer 
side  of  the  thigh.  The  anterior  crural  nerve  may  be  exposed  by  an 
incision  placed  about  1/2  inch  (i  cm.)  external  to  the  center  of 
Poupart's  ligament.  The  nerve  will  be  found  just  external  to  the 
femoral  artery.  The  sciatic  nerve  may  be  reached  for  perineural 
injection  by  inserting  the  needle  at  a  point  where  a  horizontal  line 
through  the  tip  of  the  great  trochanter  cuts  a  vertical  line  through 
the  outer  margin  of  the  tuberosity  of  the  ischium.  A  needle  about  3 
inches  (8  cm.)  long  is  reqoired.  It  is  introduced  directly  backward 
until  bone  is  reached  and  is  then  withdrawn  for  a  distance  of  1/25 
inch  (i  mm.).  After  injection  of  the  anesthetic  solution  about  1/2 
an  hour  is  required  for  complete  anesthesia.  The  sciatic  may  also  be 
blocked  after  exposure  under  infiltration  anesthesia  at  the  lower  bor- 
der of  the  gluteus  maximus  muscle,  or  at  the  upper  border  of  the  pop- 


90 


LOCAL   ANESTHESLA. 


liteal  space.     In  the  former  case,  an  incision  3  to  4  inches  (7.5  to 
10  cm.)  long  is  made  between  the  tuberosity  of  the  ischium  and  the 


Fig.  64. — Exposure  of  the  anterior  crural  and  external  cutaneous  nerves  for 
injection.  i,  Anterior  crural  nerve;  2,  external  cutaneous  nerve;  3,  femoral 
artery;  4,  femoral  vein. 

great  trochanter,  with  its  center  over  the  lower  margin  of  the  gluteus 
maximus  muscles.  By  retracting  the  gluteus  maximus  upward  and 
the  ham-string  muscles  inward,  the  nerve  will  be  found  lying  under 


Fig.  65. — Exposure  of  the  sciatic  nerve  in  the  upper  part  of  the  thigh  for  injec- 
tion. I,  Gluteus  maximus  muscle;  2,  biceps  muscle;  3,  semitendinosus  muscle; 
4,  sciatic  nerve. 


the  outer  edge  of  the  biceps  muscle  (Fig.  65).     In  the  upper  portion 
of  the  popliteal  space  the  nerve  may  be  exposed  by  a  vertical  incision 


EXDO-    AXD    PERINEURAL    IXFILTRATIOX 


91 


in  the  mid-line;  it  will  be  foancl  lying  between  the  biceps  and  semi- 
membranosus muscles.  It  should  be  injected  before  it  divides,  or 
else  both  the  internal  and  external  popliteal  nen-es  are  to  be  blocked. 


Fig.  66. — Exposure  of  the  internal  saphenous  nerve  for  injection,      i,  Internal 
saphenous  nerv^e;  2,  internal  saphenous  vein. 

In  operations  below  the  tubercle  of  the  tibia,  it  is  unnecessary  to  block 
the  anterior  crural  and  external  cutaneous;   blocking  the  sciatic  in 


Fig.  67. — Cross-section  of  the  leg  above  the  ankle-joint,  showing  the  direction 
of  the  needle  for  perineural  infiltration  of  the  posterior  tibial  nerve.  (After  Braun.) 
I,  Posterior  tibial  nerve;  2,  external  saphenous  nerve;  3,  area  of  skin  infiltration; 
4,  musculocutaneous  ner\'e;  5,  anterior  tibial  nerve;  6,  tendo  achillis;  7,  peronei 
muscles;  8,  flexor  longus  haUucis;  9,  extensor  longus  digitorum;  10,  extensor 
longus  hallucis;  li,  tibialis  anticus;  12,  tibialis  posticus;  13,  flexor  longus 
digitorum. 

the  popliteal  space  and  the  external  saphenous  as  it  passes  to  the 
inner  and  posterior  aspect  of  the  knee-joint  is  suihcient  (Fig.  66). 
Below  the  knee,  the  large  nerves  are  not  available  for  injection 


LOCAL    ANESTHESLA. 


until  the  ankle  is  reached.  Behind  the  ankle  the  posterior  tibial  may 
be  perineurally  injected  by  inserting  the  needle  on  the  inner  side  of 
the  tendo  achillis  directly  forward  almost  to  the  posterior  surface  of 
the  tibia  (Fig.  67).  The  anterior  tibial  may  be  likewise  perineurally 
injected  by  inserting  the  needle  on  the  dorsum  of  the?  ankle  between 
the  tendons  of  the  tibialis  anticus  and  the  extensor  longus  hallucis 
and  the  innermost  tendon  of  the  extensor  longus  digitorum.  By  a 
circular  strip  of  subcutaneous  inliltration.  the  remainder  of  the  sen- 
sory nerve  supply  may  be  blocked  and  complete  anesthesia  of  the  foot 
may  be  obtained. 

In  anesthetizing  the  digits  and  metatarsals,  the  same  principles 
already  described  for  the  hand  are  applicable.  Amputations  of  toes, 
operations  for  ingrowing  toe-nail,  osteotomy  for  hallux  valgus,  etc., 
may  be  readily  performed  under  perineural  injection  of  the  proper 
nerves. 

Operations  upon  Inflamed  Tissues  under  Local  Anesthesia. — 
Upon   the  extremities  some  of  the  methods  of  endoneural  or  peri- 


FiG.  68. — Showing  the  method  of  anesthetizing  an  inflamed  area. 

neural  blocking  of  the  nerves  supplying  the  region  affected  gives 
most  satisfaction.  Where  these  methods  are  not  applicable  infiltra- 
tion anesthesia  may  be  employed  if  care  is  taken  not  to  inject  the 
solution  directly  into  the  inflamed  tissues.  An  attempt  should  be 
made  to  surround  the  diseased  area  with  the  anesthetic  solution, 
making  the  injections  through  healthy  skin  into  the  subcutaneous 
tissues  (Fig.  68),  thus  cutting  oflf  all  sensory  communication  wath  the 


BIER  S   VENOUS    ANESTHESIA 


93 


surrounding  parts.  Infiltration  of  the  inflamed  tissues  should  be 
avoided  as  any  increase  in  distention  of  the  already  swollen  structures 
causes  intense  pain  and  in  some  cases  seems  to  lower  the  resistance  to 
such  an  extent  that  cellulitis  results. 

BIER'S  VENOUS  ANESTHESIA 

Quite  recehtly  Bier  has  developed  an  innovation  in  the  production 
of  local  anesthesia  in  extremities,  termed  venous  anesthesia.  It 
consists  essentially  in  rendering  the  limb  bloodless  and,  after  isolating 
the  field  of  operation  from  the  circulation  by  means  of  tourniquets 
applied  above  and  below  the  area  to  be  anesthetized,  injecting  the 
anesthetic  solution  into  one  of  the  veins  between  the  two  tourniquets. 
What  is  termed  "direct  anesthesia"  rapidly  develops  between  the 
two  bandages;  while  somewhat  later,  after  the  anesthetic  solution 
has  had  time  to  act  upon  and  paralyze  the  nerve  trunks  within  the 
isolated  area,  the  anesthesia  extends  to  the  entire  limb  beyond  the 
bandage.     This  is  termed  "indirect  anesthesia." 

Venous  anesthesia,  of  course,  is  applicable  only  to  the  extremities, 
and  it  is  not  intended  that  it  should  supplant  the  ordinary  methods  of 
local  anesthesia  which  are  sufficient  for  the  superficial  tissues;  its 
special  field  is  for  major  operations,  such  as  amputations,  resection  of 
joints,  and  operations  upon  bones,  muscles,  tendons,  etc.  According 
to  its  originator,  diabetic  and  senile  gangrene  and  arteriosclerosis  are 
contraindications  to  its  use. 

While  this  method  of  anesthesia  has  not  received  the  extended 
trial  in  the  hands  of  different  operators  that  some  of  the  older  meth- 
ods of  local  anesthesia  have,  it  has  been  thoroughly  tested  by  its 
originator  and  by  him  is  considered  to  be  far  ahead  of  other  methods 
for  producing  anesthesia  of  the  extremities.  Bier  reported  {Berliner 
klinische  Wochenschrift,  March  19,  1909)  134  operations  under  venous 
anesthesia,  including  amputations,  arthrotomies,  bone  suture,  extirpa- 
tion of  varicose  veins,  etc.,  and  of  this  total  in  115  cases  the  anesthesia 
was  perfect,  in  fourteen  satisfactory,  and  in  five  unsatisfactory.  Of 
the  latter,  however,  three  were  operations  upon  children.  In  iifteen 
cases  in  which  the  writer  has  employed  this  method  the  anesthesia  was 
all  that  could  be  desired. 

Apparatus. — A  syringe,  such  as  the  Sub-Q  or  the  Janet,  with  a 
capacity  of  about  3  ounces  (90  c.c),  Bier's  special  cannula,  a  short 
heavy  piece  of  rubber  tubing  for  connecting  the  syringe  with  the  can- 
nula, a  small  medicine  glass,    a  small  syringe  and  fine  needle  for  infil- 


94 


LOCAL   ANESTHESIA 


trating  the  site  of  operation,  a  glass  graduate  for  the  vein  solution, 
and  three  rubber  bandages,  each  2  1/2  inches  (6  cm.)  wide  and  6 
feet  (180  cm.)  long  (Fig.  69),  will  be  required. 

Bier's  cannulas  are  1/16  inch  (1.5  mm.)  in  diameter  for  children  and 
1/14  to  1/12  inch  (1.75  to  2  mm.)  in  diameter  for  adults.  The  distal 
end  of  the  cannula  is  provided  with  grooves  into  which  the  ligatures 


Fig.  69. — Apparatus  for  venous  anesthesia,  i,  Rubber  tourniquets;  2, 
medicine  glass;  3,  glass  graduate;  4,  large  glass  syringe  and  Bier's  cannula;  5, 
ampule  of  anesthetic;  6,  syringe  for  preliminary  infiltration  of  the  skin  at  the  site 
of  operation. 

with  which  it  is  tied  in  the  vein  fits,  and  at  the  other  end  there  is 
a  stopcock  and  a  bayonet  connection  (Fig.  70).  In  the  absence  of  a 
special  cannula,  an  ordinary  infusion  cannula  may  be  used,  an  artery 
clamp  applied  to  the  rubber  tubing  acting  as  a  stopcock. 


Fig.  70. — Enlarged  view  of  Bier's  cannula  for  venous  anesthesia. 


Instruments. — Instruments  necessary  for  an  ordinary  infusion  are 
required;  namely,  a  scalpel,  mouse-toothed  thumb  forceps,  a  pair  of 
blunt-pointed  scissors,  an  aneurysm  needle,  needle  holder,  two 
curved  needles  with  a  cutting-edge.  No.  2  plain  catgut,  and  a  few 
artery  clamps  (Fig.  71). 

Solution. — Bier  employs  a  0.5  per  cent,  solution  of  novocain  in 
normal  salt  solution. 


bier's  venous  anesthesia 


95 


Quantity  Used. — From  20  to  60  c.c.  (5  drams  to  2  ounces)  of 
solution  are  ordinarily  injected,  depending  upon  the  extent  of  the  area 
to  be  injected.  The  quantity  employed  should  not,  however, 
exceed  2  3/4  ounces  (80  c.c). 

Site  of  Injection. — For  the  arm,  the  basilic  vein  and  for  the  leg 
the  internal  saphenous  vein  is  usually  chosen,  though  any  of  their 
tributaries  sufficiently  large  for  the  purpose  will  answer. 

Preparations. — The  site  of  injection  is  sterilized  by  painting  with 
tincture  of  iodin.  The  instruments  are  boiled,  and  the  operator's 
hands  cleansed  as  for  any  operation. 

Technic. — The  limb  is  first  elevated  and  rendered  bloodless  by 
the  application  of  an  Esmarch  bandage  applied  from  the  extremity  of 


Fig.  71. — Instruments  for  venous  anesthesia,  i,  Scalpel;  2,  blunt-pointed 
scissors;  3,  thumb  forceps;  4,  aneurysm  needle;  5,  needle  holder;  6,  curved 
needles;  7,  No.  2  plain  catgut;  8,  artery  clamps. 

the  limb  up  to  a  point  well  above  the  site  of  injection.  Some  care 
should  be  taken  in  applying  this  bandage  as  it  is  necessary  that  the 
veins  be  thoroughly  emptied.  A  tourniquet  is  then  applied  at  the 
upper  limit  of  the  bandage  used  to  exsanguinate  the  part  by  wrap- 
ping a  soft  rubber  bandage  about  the  limb  in  broad  bands  so  as  not 
to  cause  the  patient  any  unnecessary  discomfort,  and  the  first  band- 
age is  removed  for  a  distance  of  4  to  10  inches  (10  to  25  cm.).  At 
this  point  a  second  tourniquet  is  applied  and  the  remaining  portion 
of  the  Esmarch  is  entirely  removed  (Fig.  72).  When  the  operation 
is  near  an  extremity  only  one  tourniquet  need  be  employed.  It 
should  not  be  placed,  however,  higher  than  the  middle  of  the  fore- 


96 


LOCAL    ANESTHESIA 


arm  or  leg.  Under  infiltration  anesthesia  with  a  o.  2  per  cent,  solu- 
tion of  cocain  or  a  i  per  cent,  solution  of  novocain,  one  of  the  main 
subcutaneous  veins  or  one  of  its  large  tributaries,  previously  selected, 
is  exposed  by  a  small  transverse  incision  in  the  proximal  part  of 
the  isolated  area.  The  vein  is  opened  by  cutting  with  scissors,  its 
proximal  end  is  tied  ofif,  and  the  cannula  is  secured  in  its  distal  end. 
Any  small  veins  that  may  be  cut  are  securely  clamped  to  prevent 
leakage  of  the  solution.  The  anesthetic  is  then  injected  under  con- 
siderable pressure  toward  the  periphery,^  i.e.,  against  the  valves  of 
the  veins,  until  the  superficial  veins  swell  and  the  whole  segment 
between  the  two  bandages  becomes  paler  than  before.  The  stopcock 
is  then  closed  and  the  syringe  removed,  the  cannula  being  left  in 
place  for  further  injection  if  necessary. 

In  this  way  the  anesthetic  solution  is  distributed  through  the 
tissues  between  the  two  tourniquets  and  is  brought  in  contact  with 
the  nerve  trunks  and  nerve  endings  of  the  whole  area.     Direct  anes- 


FiG.  72. — Bier's  venous  anesthesia.     Showing  the  application  of  the  bandages  and 

the  site  of  injection -|-. 


thesia  follows  between  the  bandages  in  three  to  five  minutes,  and 
indirect  anesthesia  beyond  the  distal  bandage  is  observed  in  six  to 
twenty  minutes.  If  the  proximal  bandage  causes  pain,  as  is  some- 
times the  case,  a  second  one  may  now  be  placed  immediately  below  it 
on  the  anesthetized  area  and  the  first  one  may  be  removed.  As 
a  rule,  some  motor  paralysis  occurs  in  the  anesthetized  area,  but  it 
soon  disappears  after  removal  of  the  bandages.  Anesthesia  per- 
sists as  long  as  the  bandages  remain  in  place  and  rapidly  disap- 
pears after  their  removal,  so  it  is  absolutely  necessary  that  the  op- 
eration, including  hemostasis  and  suturing,  be  completed  before  the 
bandages  are  removed.  If  difiiculty  is  experienced  in  recognizing 
cut  vessels,  sahne  may  be  injected  into  the  cannula  and  it  will  spurt 
from  the  open  ends.  The  danger  of  poisoning  from  absorption  of 
the  drug  employed  for  anesthesia  may  be  disregarded.     This  appar- 

1  Bier  in  a  later  communication  {Edinburg  Medical  Journal,  Aug.,  19 10)  states 
that  the  injection  may  also  be  made  centrally,  opening  the  vein  close  to  the  distal 
bandage. 


BIER  S   VENOUS    ANESTHESIA  97 

ent  danger  was  formerly  guarded  against  by  washing  out  the  veins 
with  saHne  at  the  end  of  the  operation.  This  precaution  is  now 
regarded  as  unnecessary,  for,  according  to  Bier,  the  anesthetic 
quickly  goes  through  the  vein  wall  and  the  greater  portion  of  it 
becomes  bound  up  in  the  tissues,  returning  to  the  circulation  very 
gradually. 

Variations  in  Technic. — Following  Bier's  lead,  others  have 
injected  local  anesthetics  into  the  arterial  system  instead  of  into  a 
vein.  Thus  Goyanes  (quoted  in  Centralhlatt  fur  Chirurgie,  1909, 
Vol.  XXVI)  describes  a  method  of  regional  anesthesia  by  the  injec- 
tion of  the  anesthetic  solution  into  an  artery.  Two  to  3  ounces  (50 
to  100  c.c.)  of  a  0.5  per  cent,  solution  of  novocain  in  normal  salt 
solution,  colored  with  a  few  drops  of  concentrated  methylene  blue  solu- 
tion so  that  the  operator  may  note  the  penetration  of  the  tissues  by 
the  anesthetic,  are  slowly  injected  by  means  of  define  needle  inserted 
obMquely  into  the  vessel  between  Esmarch  bandages  in  a  manner  very 
similar  to  the  method  of  Bier. 

Ransohoff  {Annals  of  Surgery,  April,  1910)  describes  a  method  of 
terminal  arterial  anesthesia  obtained  by  injecting  cocain  solution  into 
an  artery  supplying  the  area  of  operation.  He  reports  two  cases  in 
which  the  method  was  employed,  as  well  as  a  number  of  experiments 
upon  animals  which  would  seem  to  show  that  it  is  a  safe  and  efficient 
procedure  in  suitable  cases.  He  recommends  this  method  as  being 
especially  applicable  to  operations  upon  the  upper  extremity  where 
the  brachial,  ulnar,  or  radial  artery  may  be  exposed  without  difficulty 
and  in  operations  upon  the  foot  or  ankle  after  exposure  of  the  anterior 
tibial  artery. 

Ransohoff 's  technic  is  as  follows:  "The  main  artery  supplying 
the  part  to  be  anesthetized  is  exposed  under  infiltration  anesthesia. 
An  Esmarch  strap  is  now  bound  about  the  limb  some  distance 
above  the  point  of  proposed  injection  into  the  artery.  The  Esmarch 
should  be  used  as  in  the  Bier  hyperemic  treatment;  that  is,  snug 
enough  to  constrict  the  veins,  but  not  so  tight  as  to  interfere  with  the 
arterial  circulation.  From  4  to  8  c.c.  (i  to  2  dr.)  of  a  0.5  per  cent, 
solution  of  cocain  in  normal  salt  solution  should  be  injected  into  the 
artery  in  the  direction  of  the  blood  stream.  The  needle  used  should 
be  as  fine  as  possible.  After  anesthesia  is  complete,  the  Esmarch  may 
be  tightened  if  perfect  hemostasis  is  desired." 

It  is  claimed  that  the  cocain  thus  introduced  is  carried  by  the 
capillaries  to  the  individual  nerve  endings  and  the  solution  is  diffused 
through  the  capillary  walls  into  the  surrounding  tissues  so  that  little, 
7 


98  LOCAL   ANESTHESIA 

if  any,  solution  is  returned  to  the  general  circulation.     The  writer 
has  had  no  experience  with  the  arterial  method. 

SPINAL  ANESTHESIA 

This  form  of  anesthesia  is  produced  by  injecting  weak  solutions  of 
drugs  having  local  analgesic  properties  into  the  subarachnoid  space. 
Cocainization  of  the  spinal  cord  was  first  suggested  by  Corning  in 
1885.  Bier,  in  1899.  improved  upon  the  method  and  made  it  prac- 
ticable for  surgical  purposes. 

The  enthusiasm  with  which  spinal  anesthesia  was  first  received 
has,  however,  proved  unwarranted  by  practical  results.  The  mor- 
tality is  higher  than  from  ether  or  chloroform,  and  it  is  not  absolutely 
certain  that  permanent  harm  to  the  cord  may  not  result.  Certainly, 
cases  have  been  reported  which  would  suggest  such  a  possibility.  In 
a  certain  percentage  of  the  cases  anesthesia  does  not  develop  or  is 
incomplete,  and  at  times  most  unpleasant  symptoms  accompany 
the  anesthesia;  headache,  nausea,  vomiting,  sweating,  chills,  rise  of 
temperature,  or  collapse  are  by  no  means  rare.  Spinal  anesthesia  has 
a  place  in  surgery,  without  doubt,  but  it  should  be  reserved  for  those 
exceptional  cases  in  which  general  anesthesia  is  contraindicated 
or  other  methods  of  local  anesthesia  are  impracticable.  Recent 
syphilitic  infections,  diseases  of  the  brain  and  spinal  cord,  marked 
curvature  of  the  spine,  and  cases  of  general  septicemia  are  contra- 
indications to  spinal  anesthesia. 

Injections  have  been  made  in  all  portions  of  the  cord,  but  for 
practical  surgical  purposes  they  are  now  limited  to  the  lumbar  region. 
The  danger  of  inducing  respiratory  paralysis  is  too  great  to  warrant 
the  introduction  of  analgesics  into  the  higher  regions  of  the  cord.^ 

Solutions  Used. — All  the  various  local  anesthetics  have  been  used, 
but  at  the  present  time  stovain  and  tropacocain  are  the  drugs  most 
frequently  employed  for  spinal  anesthesia. 

Cocain  is  now  generally  discarded  for  some  of  the  less  dangerous 
substitutes.  If  employed,  it  may  be  used  in  a  2  per  cent,  solution  in 
normal  salt  solution,  10  to  4oTrL  (0.6  to  2.5  c.c.)  of  such  a  solution, 
containing  between  1/5  and  i  gr.  (0.01296  and  0.065  gm.)  of  cocain, 
are  injected.  The  addition  of  a  few  drops  of  a  i  to  1000  solution  of 
adrenahn  chlorid  to  the  cocain  is  said  to  be  of  great  benefit,  prevent- 
ing the  rapid  difi'usion  of  the  anesthetic,  and  many  of  the  impleasant 
after-effects. 

Stovain  is  less  toxic  than  cocain  and  is  very  highly  recommended 


SPINAL   ANESTHESIA  .99 

by  many  authorities.  A  5  per  cent,  solution  is  used,  the  dose  being 
3/4  to  I  gr.  (0.0486  to  0.065  gm.). 

Novocain  is  also  frequently  employed.  It  is  about  seven  times 
less  poisonous  than  cocain.  A  5  per  cent,  solution  in  normal  salt 
solution  is  employed.  The  ordinary  dose  is  from  3/4  to  i  1/2  gr. 
(0.0486  to  0.0974  gm.). 

Tropacocain  is  another  substitute  for  cocain  frequently  used,  and 
the  anesthesia  is  more  lasting.  It  is  given  in  a  dose  of  from  1/2  to 
I  gr.  (0.0324  to  0.065  gm.)  in  a  5  per  cent,  solution. 

At  the  present  time  many  operators  employ  solutions  with  a  higher 
or  a  lower  specific  gravity  than  the  cerebrospinal  fluid,  so  that  when 
the  solution  is  injected  it  will  either  fall  or  rise.  To  render  the  solu- 
tion lighter  or  more  diffusible  alcohol  is  added.  Babcock  (/.  A .  M.  A., 
Oct.  II,  19 13)  gives  the  following  formulas  for  light  solutions: 


A.  Stovain, 
Lactic  acid, 
Absolute  alcohol, 
Distilled  water, 

B.  Tropacocain, 
Absolute  alcohol, 
Distilled  water, 

C.  Novocain, 
Absolute  alcohol, 
Distilled  water. 

One  to  1.5  c.c.  (16  to  25  minims)  of  these  mixtures  is  given  as  the  adult  dose. 

Barker  employs  the  following  solution: 

Stovain,  five  parts 

Glucose,  five  parts 

Distilled  water,  ninety  parts  (all  by  weight). 

This  solution  is  heavier  than  the  cerebrospinal  fluid,  having  a 
specific  gravity  of  1023  against  1007  for  the  cerebrospinal  fluid,  and 
sinks  to  the  lowest  level  of  the  canal.  It  is,  therefore,  possible  to 
obtain  an  anesthesia  at  any  level  by  adjusting  the  patient's  position 
by  the  aid  of  pillows  so  that  the  desired  vertebra  lies  at  the  lowest 
level. 

The  injection  of  a  solution  of  Epsom  salt  has  been  advocated  by 
Meltzer,  Haubold,  and  others.  Sixteen  minims  (i  c.c.)  of  a  25  per 
cent,  solution  are  given  for  every  25  pounds  (10  K.)  of  body  weight. 
Three  to  four  hours  after  the  injection  paralysis  and  analgesia  in  the 


(Approximately) 

0.08  gm. 

I  1/4  gr- 

0.04  c.c. 

2/3  gr- 

0.  2  c.c. 

3  minims 

1.8  c.c. 

30  minims 

0. 1  gm. 

I  1/2  gr. 

0.2   c.c. 

3  minims 

1.8  c.c. 

30  minims 

0. 16  gm. 

2  1/2  gr. 

0.  2  c.c. 

3  minims 

1.8  c.c. 

30  minims 

lOO 


LOCAL   ANESTHESIA 


legs  and  pelvic  regions  appear  and  persist  for  from  eight  to  fourteen 
hours.  It  is  claimed  that  ov^erdosage  endangers  life  from  respiratory 
paralysis. 

Apparatus. — A  special  stylet  needle  and  an  appropriate  syringe 
with  a  capacity  of  about  i  1/4  drams  (5  c.c.)  should beprovided.  The 
needle  should  be  of  platinum  or  nickel,  1/25  inch  (i  mm.)  in 
diameter,  and  about  3  3/4  inches  (9.5  cm.)  long.  The  stylet  must  be 
ground  to  a  point  with  the  needle  and  should  fit  the  latter  accurately 
at  the  point,  to  avoid  carrying  in  fragments  of  tissue  as  it  traverses 
the  flesh.  It  is  important  that  the  point  of  the  needle  be  not  too 
long — the  more  transversely  it  is  ground  the  better.  With  a  short- 
pointed  needle  the  liability  of  injecting  only  a  portion  of  the  solution 


Fig.  73. — Apparatus  for  spinal  anesthesia,  i,  Ethyl  chlorid;  2,  medicine 
glasses,  one  for  receiving  the  spinal  fluid  and  the  other  for  the  anesthetic  solution ; 
3,  ampule  containing  the  anesthetic;  4,  scalpel;  5,  syringe  and  trocar. 


into  the  canal  and  part  outside  the  subarachnoid  space  is  quite  remote. 
In  addition,  a  scalpel  for  making  the  preliminary  puncture  and  ster- 
ilized medicine  glasses  for  holding  the  solution  to  be  injected  should  be 
provided  (Fig.  73). 

Location  of  the  Puncture. — Any  of  the  spaces  between  the  second 
lumbar  and  the  first  sacral  vertebra  is  available  for  the  puncture,  but 
the  usual  site  is  between  the  third  and  fourth,  or  the  fourth  and 
fifth  lumbar  vertebra  (Fig.  74).  The  spaces  may  be  identified  by 
counting  down  from  the  seventh  cervical  vertebra.  If  this  is  difficult 
on  account  of  excess  of  fat,  the  fourth  lumbar  spinous  process  may  be 
readily  located,  and  from  it  the  other  vertebrae,  by  passing  a  line 
between  the  highest  points  of  the  iliac  crests.  Such  a  line  passes 
through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra 


SPINAL   ANESTHESIA 


lOI 


(Fig.  75).  Puncture  in  the  mid-line  is  generally  practised,  as  it 
insures  the  solution  being  more  evenly  distributed  on  both  sides  of 
the  cord  and  lessens  the  chance  of  a  one-sided  analgesia.     A  point 


Fig.  74. — Points  for  injecting  the  anesthetic  solution  in  spinal  anesthesia. 

between  the  two  spines  in  the  mid-line  is  chosen,  and  starting  from 
this  point  the  needle  is  passed  slightly  upward  and  forward  between 
the  spinous  processes.     The  average  space  available  for  the  puncture 


Fig.  75. — Showing  the  method  of  locating  the  fourth  spinous  process  by  passing  a 
line  through  the  highest  points  of  the  iliac  crests. 

between  the  bones  in  the  lumbar  portion  of  the  cord  is  18/25  to  4/5 
inch  (18  to  20  mm.)  in  the  transverse,  and  2/5  to  3/5  inch  (10  to 
15  mm.)  in  the  vertical  diameter. 


I02 


LOCAL   ANESTHESIA. 


Asepsis. — The  operation  should  be  performed  with  the  greatest 
aseptic  care.  The  needle  and  syringe  should  always  be  boiled  in 
plain  water,  the  solution  injected  must  be  sterile,  and  the  operator's 
hands  and  site  of  ooeration  should  be  prepared  with  all  the  care  that 
would  be  observed  in  any  operation. 


Fig.  76. — Sitting  position  for  spinal  puncture. 

Preparation  of  the  Patient. — This  should  be  the  same  as  for  an 
operation  under  general  anesthesia  (see  page  2).  If  the  operation 
is  to  be  a  prolonged  one,  morphin  gr.  1/4  (0.0162  gm.)  should  be 
given  hypodermically  half  an  hour  beforehand. 


Fig.  77. — Lateral  position  for  spinal  puncture. 


Position  of  the  Patient. — The  body  of  the  patient  is  curved  well 
forward  so  as  to  widen  the  intervertebral  spaces  as  much  as  possible. 
For  this  purpose  the  patient  sits  up,  leaning  well  forward,  with  his 
back  to  the  operator  (Fig.  76),  or  else  lies  upon  one  side  with  the 
back  in  the  form  of  an  arch  (Fig.  77). 


SPINAL    ANESTHESIA 


103 


Technic. — The  spot  chosen  for  the  puncture  is  anesthetized  with 
ethyl  chlorid  or  by  infiltration  with  a  few  drops  of  cocain,  and  a  small 
puncture  is  made  in  the  skin  with  a  scalpel  (Fig.  78),  to  lessen  the 
danger  of  carrying  in  infection  with  the  needle.  The  operator  then 
identifies  with  his  finger  a  point  in  the  mid-line  between  the  two  spi- 
nous processes  bounding  the  space  for  the  puncture,  and  inserts  the 
needle  armed  with  its  stylet  in  a  slightly  upward  and  forward  direc- 
tion until  it  enters  the  subarachnoid  space  (Fig.  79).  Lessened  resist- 
ance, followed  by  the  escape  of  the  fluid  from  the  needle,  determines 
when  this  is  accomplished.  The  distance  necessary  to  be  traversed 
varies  from  i  to  i  1/2  inches  (2.5  to  4  cm.)  in  a  child,  2  1/2  to  3  inches 


Fig.  78. 
Pig.  78. — Spinal  anesthesia. 
Fig.  79. — Spinal  anesthesia. 


Fig.  79. 
First  step,  nicking  the  skin  at  the  site  of  puncture. 
Second  step,  inserting  the  needle. 


(6  to  7.5  cm.)  in  an  adult.  In  inserting  the  needle,  if  it  strikes  bone,  it 
should  be  withdrawn  slightly  and  its  direction  changed.  The  cere- 
brospinal fluid  should  gush  out  with  some  force  on  removal  of  the 
stylet  and  should  be  clear.  If  only  a  few  drops  escape  or  the  fluid  is 
reddish  in  color  it  indicates  that  the  needle  is  not  properly  inserted, 
and  a  new  puncture  should  be  made.  A  quantity  of  cerebrospinal 
fluid,  corresponding  to  the  amount  of  anesthetic  to  be  injected,  should 
be  allowed  to  escape  before  the  analgesic  solution  is  introduced  (Fig. 
81).  This  will  vary  from  10  to  4oTn,  (0.6  to  2.5  c.c),  according  to 
the  strength  of  the  solution  to  be  used.  As  soon  as  the  desired 
quantity  of  cerebrospinal  fluid  has  escaped,  the  flow  is  stopped  by 


I04 


LOCAL    ANESTHESIA 


placing  a  finger  over  the  end  of  the  needle,  and  the  syringe,  filled 
with  the  proper  amount  of  solution,  is  attached.  Some  operators 
prefer  to  dissolve  the  analgesic  agent  in  the  cerebrospinal  fluid  with- 


FlG.  80. — Showing  the  direction  of  the  needle  in  entering  the  spinal  canal. 


Fig.  81.  Fig.  82. 

Fig. '8 1. —Spinal  anesthesia.  Third  step,  allowing  the  cerebrospinal  fluid  to 
escape. 

Fig.  82. — Spinal  anesthesia.  Fourth  step,  injecting  the  anesthetic  solution. 

drawn  and  reinject  the  solution  thus  formed.  The  solution  should 
always  be  slowly  introduced  (Fig.  82).  The  needle  is  then  with- 
drawn  and   the  puncture  sealed  with  collodion  and  cotton,  or  is 


SPINAL   ANESTHESIA  105 

dressed  with  a  piece  of  gauze  held  in  place  by  adhesive  plaster.  If  a 
heavy  solution  is  employed  and  the  operator  desires  a  low  anesthesia 
only,  the  patient  is  kept  in  the  upright  position  for  a  few  moments 
after  the  injection  to  allow  the  solution  to  gravitate  downward,  but, 
if  a  light  solution  is  used,  the  patient's  head  must  be  immediately 
lowered  to  prevent  its  rapid  spread  upward. 

As  the  solution  comes  in  contact  with  the  nerve  roots  it  blocks 
their  conductivity,  and  in  from  ten  to  fifteen  minutes  loss  of  sensation, 
often  accompanied  by  muscular  paralysis,  takes  place.  The  anesthe- 
sia becomes  marked  first  in  the  anal  and  perineal  regions,  and  then  in 
the  lower  extremities,  being  limited  above,as  a  rule,  to  a  zone  not  higher 
than  the  waist  line.  With  a  successful  injection,  any  operation  about 
the  lower  extremities,  the  anus,  perineum,  or  pelvis  may  be  readily 
performed.  The  anesthesia  thus  obtained  persists  for  two  hours  or 
longer. 

Following  the  operation  the  patient  is  kept  recumbent  in  bed  with 
the  upper  part  of  his  body  slightly  raised  and  is  not  permitted  to  sit 
upright  for  twenty-four  hours. 

Sacral  Anesthesia. — The  idea  of  anesthetizing  the  sacral  nerves 
by  injecting  drugs  into  the  extra-dural  space  through  the  lower  end 
of  the  sacral  canal  originated  with  Cathelin.  Later  the  method  was 
employed  in  obstetrics  for  the  purpose  of  obtaining  painless  deliver- 
ies, but  it  never  came  into  general  use.  More  recently  sacral  anes- 
thesia has  been  revived  and  the  technic  improved  by  Lawen  and 
others  to  such  an  extent  that  the  method  is  now  of  recognized  value  in 
operations  upon  the  genital  and  anal  regions  below  the  level  of  the 
fifth  lumbar  nerve. 

Like  spinal  anesthesia,  the  sacral  method  fails  in  a  certain  propor- 
tion of  cases  even  in  the  hands  of  those  skilled  in  its  use,  and  in  some 
cases  only  partial  anesthesia  is  obtained.  Most  of  the  failures  are 
met  with  in  very  stout  individuals.  In  a  successful  case  the  anes- 
thesia usually  lasts  for  from  3/4  to  an  hour.  The  anesthesia  is 
not  accompanied  by  unpleasant  symptoms,  such  as  headache  and 
vomiting,  that  are  sometimes  observed  in  spinal  anesthesia,  though 
a  transient  pallor,  acceleration  of  the  pulse,  and  a  fall  in  blood- 
pressure  may  occur. 

Anatomy. — Upon  the  dorsal  surface  of  the  sacrum  in  the  median 
line  may  be  recognized  the  spinous  processes  of  the  three  or  four  upper 
vertebras,  the  fourth  spine  sometimes,  and  the  fifth  spine  always  being 
absent  through  failure  of  the  lamina  to  coalesce.  A  triangular  gap, 
known  as  the  hiatus  sacralis,  is  thus  formed  through  which  a  needle 


io6 


LOCAL   ANESTHESLV 


may  be  readily  passed  into  the  sacral  canal.  The  lower  margins  of 
this  opening  are  prolonged  downward  as  two  tubercles,  the  sacral 
cornua  (Fig.  83). 


^acraJ  canal 


Sacral 
Sacra.1  cornu 
hiatus 


Fig.  83. — The  posterior  surface  of  the  sacrum,  showing  the  hiatus  sacralis. 

The  sacral  canal  contains  the  lower  end  of  the  cauda  equina,  the 
lilum  terminale,  and  the  spinal  dura.  The  latter  extends  to  the  level 
of  the  second  sacral  vertebra  or  to  within  21/2  inches  (6  cm.)  of  the 
hiatus  (Fig.  84). 


fllum  termmelt 

Fig.  84. — Showing  the  interior  of  the  sacral  canal. 


Instruments. — The  instruments  required  are  the  same  as  for 
spinal  anesthesia  (page  100),  except  a  larger  syringe — one  with  a 
capacity  of  about  5  drams  (20  c.c.) — will  be  found  preferable. 


SPINAL  ANESTHESIA  107 

Solutions  Used. — Cocain,  novocain,  and  quinin  and  urea  have  all 
been  used  for  sacral  anesthesia,  but  novocain  is  the  drug  generally 
employed.  It  is  claimed  that  the  addition  of  sodium  bicarbonate  to 
the  novocain  solution  adds  to  the  anesthetic  effect.  The  solution  is 
made  up  as  follows: 

Sodium  bicarb,  puriss.,  0.25  gm.  (3  3/4  gr.) 

Sodium  chlorid,  0.5  gm.  (8  gr.) 

Novocain,  i  gm.  (15  gr.) 

This  is  dissolved  in  100  c.c.  (3  1/3  ounces)  of  cold  sterile  distilled 
water,  and  is  sterilized  by  boiling.  When  it  has  cooled,  5  drops  of  a 
I  to  1000  adrenalin  chlorid  solution  are  added.  The  quantity  of 
novocain  used  at  a  dose  is  from  0.4  to  0.6  gm.  (6  to  9  gr.). 

Asepsis. — The  instruments  are  sterilized  by  boiling  in  plain  water, 
the  solution  is  boiled,  and  the  operator's  hands  are  cleansed  as  for 
any  operation.  The  patient's  skin  at  the  site  of  proposed  puncture 
is  painted  with  tincture  of  iodin. 

Site  of  Puncture. — The  puncture  is  made  in  the  median  line 
through  the  lower  end  of  the  sacral  canal.  The  opening  is  identified 
by  palpating  the  spinous  processes  of  the  sacrum  downward  until  it 
is  felt  that  they  divide  in  a  fork-like  manner,  forming  the  boundaries 
of  a  triangular  area,  the  hiatus. 

Position  of  Patient. — The  patient  should  be  in  the  Sims  position. 

Preparation  of  Patient. — The  patient  is  given  by  hypodermic  half 
an  hour  before  the  operation  morphin  gr.  1/6  (0.0108  gm.)  and  atro- 
pin  gr.  i/ioo  (0.00065  g^i-)-  To  this  may  be  added  scopolamin 
gr.  i/ioo  (0.00065  gm.),  if  the  operation  is  especially  difficult  or 
prolonged. 

Technic. — The  point  of  proposed  puncture  is  located  and  the 
skin  is  infiltrated  with  a  0.2  per  cent,  solution  of  cocain  or  a  i  per 
cent,  solution  of  novocain.  A  small  nick  is  then  made  in  the  skin, 
and  the  needle,  with  the  trocar  in  place,  is  inserted  at  an  angle  of 
about  45  degrees  until  it  strikes  the  bone  forming  the  anterior  wall  of 
the  canal  (Fig.  85).  The  trocar  is  then  withdrawn,  and  the  direction 
of  the  needle  is  changed  to  correspond  with  the  direction  of  the  sacral 
canal.  It  is  then  pushed  into  the  canal  for  a  distance  of  about  an 
inch  (2.5  cm.).  If  the  needle  is  in  the  canal  its  point  may  be  freely 
moved  about,  and,  upon  making  a  test  injection  with  normal  salt 
solution,  the  solution  can  be  injected  with  ease.  If  difficulty  is  met 
in  inserting  the  needle,  the  sacral  opening  may  be  first  exposed  by 
an  incision  under  infiltration  anesthesia  as  recommended  by  Lynch. 


io8 


LOCAL   ANESTHESIA 


A  little  blood  may  flow  from  the  needle,  due  to  injury  to  some 
small  veins,  and  may  be  disregarded,  but,  if  the  bleeding  is  profuse, 
or  if  blood  escapes  in  spurts,  the  injection  should  be  abandoned; 
the  same  is  true  if  clear  fluid  escapes  from  the  needle  indicating  that 
the  dura  has  been  punctured.     The  anesthetic  solution  should  be 


Fig.  85. — Direction  taken  by  the  needle  in  entering  the  sacral  canal. 

injected  very  slowly,  and,  when  the  desired  quantity  has  been  intro- 
duced, the  needle  is  removed  and  the  point  of  puncture  is  sealed  with 
collodion  and  cotton.  The  patient  is  then  brought  into  position  for 
operation,  and  in  from  3  to  5  minutes  the  anesthesia  is  complete. 


CHAPTER  HI 
SPHYGMOMANOMETRY 

Sphygmomanometry  is  the  instrumental  estimation  of  arterial 
blood-pressure.  The  determination  of  blood-pressure  has  become  a 
subject  of  such  practical  importance  that  both  physicians  and  sur- 
geons should  be  familiar  with  the  technic.  In  certain  cases  it  is 
often  of  the  greatest  value  not  only  in  making  a  diagnosis,  but  for 
purposes  of  prognosis  and  as  a  guide  to  the  treatment.  It  is  es- 
pecially important  in  surgical  work  in  determining  the  fitness  of  a 
subject  for  anesthesia  (see  also  page  4)  and  during  an  operation 
in  revealing  impending  danger  from  shock  or  cardiac  weakness. 
For  the  latter  purposes  it  should  be  employed  as  a  routine  in  all 
serious  operations  likely  to  be  attended  by  shock  or  considerable 
hemorrhage. 

In  studying  blood-pressure  two  measurements  are  made,  namely, 
the  systolic  and  the  diastolic  pressure,  and  from  these  readings  the 
pulse  pressure  and  the  mean  pressure  are  determined.  The  systolic 
pressure  is  the  maximum  pressure  caused  by  the  systole  of  the  heart; 
diastolic  pressure  is  the  minimum  pressure  in  the  artery.  The  pulse 
pressure  is  the  difference  between  the  systolic  and  the  diastolic  pres- 
sure; while  the  mean  pressure  is  the  arithmetic  mean  of  the  systolic 
and  diastolic  pressures;  for  example,  if  the  systolic  pressure  is  esti- 
mated at  145  mm.  and  the  diastolic  pressure  at  105  mm.,  the  mean 
pressure  would  be  125  mm. 

The  instrument  employed  for  estimating  blood-pressure  consists 
essentially  of  a  hollow  rubber  band  for  compression  of  an  artery,  con- 
nected with  a  manometer  and  inflating  bulb.  The  amount  of  pres- 
sure necessary  to  obliterate  the  pulse  distal  to  the  point  of  constric- 
tion measured  in  millimeters  of  mercury  represents  the  systolic  blood- 
pressure.  The  diastolic  pressure  is  obtained  by  gradually  releasing 
the  air  from  the  compression  band  after  the  pulse  has  been  obliterated 
and  noting  the  oscillations  of  the  column  of  mercury  in  the  manom- 
eter, the  base  line  of  the  greatest  oscillation  representing  the  dias- 
tolic pressure.  Both  systolic  and  diastolic  pressure  should  be  taken 
when  it  is  possible,  but  of  the  two  the  determination  of  the  systolic 

log 


no  SPHYGMOMANOMETRY 

pressure  is  of  most  importance,  as  pathological  conditions  affect  it 
more  than  the  diastolic. 

The  average  normal  systolic  pressure  obtained  with  the  wide  (12 
cm.)  armlet,  according  to  Janeway,  is  as  follows: 

For  children  up  to  two  years,  75~QO  mm.  of  mercury 

For  children  over  two  years,  90-110  mm.  of  mercury 

For  adults,  100-130  mm.  of  mercury 

In  females  the  pressure  is  about  10  mm.  less  than  in  males.  After 
middle  life  the  pressure  generally  reads  higher — often  as  high  as  145 
mm.  A  systolic  pressure  between  145  and  90  mm.  in  an  adult  may, 
therefore,  be  considered  within  the  limits  of  health.  If,  on  repeated 
examinations,  the  pressure  registers  above  or  below  these  limits,  it 
should  be  viewed  with  suspicion.  A  pressure  above  200  mm.  is 
considered  very  high  and  below  70  mm.  very  low,  while  below  45  to 
40  mm.  the  pulse  can  rarely  be  recognized.  The  diastolic  pressure 
normally  registers  25  to  40  mm.  less  than  the  systolic.  If  the  differ- 
ence between  the  two  is  less  than  20  mm.  or  more  than  50  mm.,  it 
indicates,  in  the  first  instance,  an  abnormally  small  pulse,  and,  in  the 
latter  case,  an  abnormally  large  pulse. 

As  blood-pressure  is  dependent  upon  the  quantity  and  velocity  of 
the  blood  entering  the  circulation  with  the  contraction  of  the  left 
ventricle,  the  elasticity  of  the  arterial  walls,  the  volume  of  blood  in 
the  circulation,  and  on  the  resistance  in  the  peripheral  vessels,  it  can 
be  readily  seen  that  it  may  be  subject  to  considerable  variation  in 
health  and  may  be  modified  by  many  circumstances.  Anything 
which  increases  one  or  other  of  these  factors  will  raise  the  blood-pres- 
sure and  vice  versa.  Thus  a  recent  meal,  fear,  anxiety,  self-conscious- 
ness, mental  application,  pain,  drugs  which  act  upon  the  vascular 
system,  such  as  camphor,  caffein,  strychnin,  digitalis,  adrenalin,  etc., 
increase  blood-pressure.  Cold  causes  a  rise  in  blood-pressure  through 
its  constricting  effect  upon  the  peripheral  vessels;  warmth  has  the 
opposite  effect.  Smoking  likewise  increases  it  if  it  has  a  stimulating 
effect,  but  causes  it  to  fall  if  it  depresses.  Exercise  has  the  same 
effect,  that  is,  it  increases  pressure  unless  it  is  carried  to  exhaustion, 
when  the  pressure  falls.  The  posture  of  the  individual  also  modifies 
the  pressure  reading,  it  being  10  to  15  mm.  higher  with  the  person 
standing  than  when  lying  down.  Likewise,  the  pressure  is  generally 
higher  in  the  afternoon.  The  size  of  the  encircling  band  is  also  impor- 
tant, the  narrow  bands  giving  a  higher  reading  than  the  broad  ones. 
Furthermore,  as  the  estimation  of  pressure  depends  on  the  tactile 


SPHYGOMOMANOMETRY 


III 


sense  of  the  individual  palpating  the  pulse,  the  pressure  readings  in  the 
same  patient  will  vary  somewhat  with  different  observers.  There- 
fore, to  avoid  these  sources  of  error  and  obtain  readings  of  value  for 
comparison,  the  determination  of  pressure  should  always  be  made  by 
the  same  observer,  under  the  same  conditions,  at  the  same  time  of  day, 
with  the  patient  in  the  same  position,  and  at  rest  mentally  and 
physically,  and  employing  the  same  size  armlet. 

Instruments. — There  have  been  a  number  of  excellent  sphyg- 
momanometers devised,  such  as  the  Riva-Rocci,  Stanton,  Erlanger, 
Janeway,  Hill  and  Barnard,  Faught,  Rogers,  etc.  A  few  of  these  will 
be  described. 


Fig.  86. — The  Riva-Rocci  Sphygmomanometer. 

The  Riva-Rocci  sphygmomanometer  (Fig.  86),  as  modified  by 
Cook,  consists  of  a  portable  manometer  with  a  jointed  tube  and  scale 
reading  up  to  320  mm.  The  armlet  consists  of  a  rubber  bag  4  1/2 
inches  (11.5  cm.)  wide  by  16  inches  (40  cm.)  long,  covered  with  can- 
vas, and  suppHed  with  hooks  and  eyes  for  fastening  it  in  place.  A 
Richardson  double  inflating  bulb  is  connected  with  the  armlet,  and 
also  with  the  manometer  by  means  of  a  glass  T-tube  and  rubber  tub- 
ing. A  second  glass  T-tube  is  inserted  in  the  rubber  tubing  near  the 
manometer,  to  the  long  arm  of  which  is  attached  a  short  rubber  tube 
supplied  with  a  pinchcock,  for  the  purpose  of  releasing  the  pressure. 


112 


SPHYGMOMANOMETRY 


Fig.  87. — Stanton's  Sphygmomanometer. 


Fig.  88. — Janeway's  Sphygmomanometer. 


SPHYGMOMANOMETRY 


113 


Stanton's  instrument  (Fig.  87)  consists  of  a  rubber  compression 
armlet  4  1/2  inches  (11.5  cm.)  wide  by  16  inches  (40  cm.)  long, 
inclosed  in  a  cuff  of  leather  or  thick  canvas  reinforced  by  tin  strips. 
In  the  center  of  the  cuff  is  cemented  a  glass  tube  1/4  inch  (6  mm.) 
in  diameter.  The  manometer  consists  of  a  metal  cistern  connected 
by  a  metal  tube  with  a  glass  mercury  tube  having  a  scale  registering 
to  300  mm.  The  metal  cistern  is  provided  with  a  screw  cap  having  a 
T-shaped  metal  tube,  one  arm  of  which  is  connected  with  the  armlet 
and  the  other  with  the  inflating  apparatus,  which  consists  of  a  double 
inflating  bulb.  At  the  top  of  the  metal  cistern  is  a  screw  valve  for 
the  gradual  release  of  pressure,  and  on  the  arm  connected  with  the 
inflating  apparatus  is  a  stopcock  to  shut  off  the  inflation. 

Janeway's  instrument  (Fig.  88)  consists  of  a  U-shaped  manometer 
with  a  sliding  scale,  connected  with  a  cistern,  to  one  side  of  which  is 
attached  the  armlet  and  to  the  other  a  Politzer  bag  for  the  purpose  of 


— Rogers'  Sphygmomanometer. 


inflation.  The  armlet  is  a  closed  rubber  bag  measuring  4  3/4  inches 
(12  cm.)  in  width  and  18  inches  (45  cm.)  in  length,  inclosed  in  a 
leather  cuff  that  is  fastened  to  the  limb  by  means  of  two  straps.  A 
stopcock  containing  a  needle  valve  for  the  release  of  pressure  is  inter- 
posed between  the  cistern  and  inflating  bag.  The  instrument  is 
unassembled  for  packing  in  its  case  as  follows:  The  scale  is  sHd  down 
and  the  upper  part  of  the  manometer  is  removed  and  placed  in  rings 
provided  for  this  purpose  on  the  lid.  The  open  end  of  the  manometer 
is  plugged  by  a  small  cork  "A"  and  the  other  end  is  closed  automatic- 
ally when  the  lid  is  shut  by  a  block  which  compresses  the  rubber 
"B."  The  inflation  bulb  is  removed,  and,  as  the  box  shuts,  the  stop- 
cock slips  under  a  spring  "C." 

Rogers'  Sphygmomanometer  (Fig.  89)  registers  blood-pressure 
by  means  of  an  aneroid  scale.  The  instrument  consists  of  a  rubber 
armlet  connected  by  two  tubes  with  a  gage  and  an  inflating  bulb. 


114 


SPHYGMOMANOMETRY 


The  dial  registers  from  o  to  260  mm.  of  mercury.  Upon  the  tube 
leading  from  the  inflating  bulb  is  placed  a  valve  for  releasing  the  air 
from  the  armlet.  The  readings  obtained  by  this  instrument  corre- 
spond very  closely  to  the  figures  obtained  with  the  mercury  instru- 
ments, and  the  instrument  has  an  advantage  over  the  latter  in  its 
simplicity  and  ease  of  operation. 

Whatever  form  of  instrument  is  employed,  a  wide  armlet  (4  1/2  to 
4  3/4  inches  (11.5  to  12  cm.))  should  be  used. 

Site  of  Application. — The  compression  band  may  be  applied  to  the 
arm  or  the  thigh,  the  former  being  preferable. 

Position  of  Patient. — The  patient  should  be  recumbent  with  the 
part  subjected  to  pressure  on  a  level  with  the  heart, 

Technic  {Riva-Rocci  Instrument). — The  armlet  is  fastened  about 
the  arm  midway^ between  the  shoulder  and  elbow  by  passing  the  open 
end  of  the  cuff  beneath  the  band  on  the  closed  end  and  hooking  it  in 
place.  The  manometer  is  placed  upon  a  table  near  by,  and  care  is 
taken  to  see  that  the  upper  portion  of  the  mercury  tube  is  fitted 
securely  in  the  top  of  the  lower  one  and  that  the  mercury  is  at  the  zero 
point.  The  inflating  bulb  is  then  properly  connected  with  the  arm- 
let and  manometer,  and  the  pinchcock  is  closed.  The  examiner, 
with  the  fingers  of  one  hand  palpating  the  patient's  pulse,  gradually 
inflates  the  armlet  by  squeezing  the  bulb  with  the  other  hand  until 
the  pressure  obliterates  the  pulse,  when  the  height  of  the  mercury  is 
noted.  The  mercury  is  then  allowed  to  drop  slowly  until  the  pulse 
just  reappears  which  represents  the  systolic  pressure.  For  the  sake 
of  greater  accuracy,  this  maneuver  is  repeated  by  squeezing  and  relax- 
ing the  reservoir  bulb. 

Stanton's  Instrument. — The  armlet  is  buckled  in  place  and  is  con- 
nected with  the  manometer,  the  scale  of  which  is  adjusted  so  that  the 
mercury  registers  zero.  With  the  valve  "B"  closed  and  cock  "A" 
open,  and  with  the  lingers  of  the  operator  on  the  patient's  pulse,  the 
armlet  is  slowly  inflated  until  the  pressure  causes  the  pulse  to  dis- 
appear. The  inflation  cock  "A"  is  then  closed  and  valve  "B"  is 
gradually  opened  until  the  pulse  just  reappears.  The  height  of  the 
mercury  when  this  occurs  represents  the  systoKc  pressure.  The  pres- 
sure is  further  slowly  reduced  a  few  millimeters  at  a  time,  and,  as  the 
mercury  falls,  its  column  oscillates  up  and  down,  increasing  in  size 
until  a  maximum  is  reached  and  then  diminishing.  The  base-line  of 
the  maximum  oscillations  represents  the  diastoKc  pressure,  which  is 
normally  25  to  40  mm.  below  the  systolic  pressure. 

Janeway^s  Instrument. — The  armlet  is  properly  secured  about  the 


SPHYGMOMANOMETRY 


115 


limb  as  described  above  and  the  scale  is  so  adjusted  that  the  level  of 
the  two  columns  of  mercury  is  at  zero.  With  the  fingers  on  the  radial 
pulse  the  armlet  is  gradually  inflated  by  compressing  the  bulb 
until  the  pulse  disappears.  Then,  by  slowly  releasing  the  bulb  until 
the  pulse  just  returns,  the  systolic  pressure  is  estimated.  In  cases  of 
very  high  pressure,  it  may  be  necessary  to  employ  more  than  one  bulb 
full  of  air  to  obliterate  the  pulse.  In  such  a  case,  the  stopcock  is 
closed,  and,  after  the  bag  is  refilled,  the  cock  is  opened  again  and  the 
pressure  raised  as  high  as  desired.  The  diastolic  pressure  is  obtained 
in  the  same  manner  as  described  under  the  technic  with  the  Stanton 
sphygmomanometer. 


Fig.  90. — Technic  of  sphygmomanometry  with  the  Stanton  instrument. 

Rogers^  Instrument. — The  compression  band  is  applied  about  the 
arm  like  a  bandage  and  is  secured  by  slipping  the  free  end  under  the 
last  turn.  The  aneroid  gage  is  hung  from  a  hook  on  the  outer  aspect 
of  the  armlet  and  the  gage  and  inflating  bulb  are  properly  connected. 
To  measure  the  systolic  pressure  the  cuff  is  inflated  until  the  radial 
pulse  is  obliterated,  and  the  pressure  in  the  cuff  is  raised  i  to  2  mm. 
higher.  Air  is  then  allowed  to  escape  slowly  from  the  armlet  until 
the  radial  pulse  beats  just  reappear.  The  figure  on  the  dial  at  which 
the  hand  points  at  this  moment  represents  the  systolic  pressure.  The 
diastolic  pressure  is  obtained  by  allowing  air  to  escape  from  the  arm- 
let very  slowly  until  the  dial  shows  a  maximum  range  of  oscillations. 
The  valve  is  then  quickly  closed  and  the  minimum  oscillation  is 
taken  as  the  diastolic  pressure. 


ii6 


SPHYGMOMANOMETR  Y 


The  Auscultatory  Method  of  determining  systolic  and  diastolic 
pressure  is  carried  out  by  the  aid  of  a  stethoscope  instead  of  by  pal- 
pation. The  cuff  is  applied  and  the  pulse  obliterated  in  the  usual 
way.  The  operator  then  places  a  stethoscope  over  the  brachial 
artery  below  the  cuff  and  listens  for  the  reappearance  of  the  first 
sound  (Fig.  91).  The  height  of  the  column  of  mercury  when  this 
occurs  represents  the  systolic  pressure.  If  the  armlet  be  further 
deflated  there  will  still  be  heard  murmurs  which  rapidly  disappear 
when  the  mercury  drops  30  to  45  mm.  below  the  systolic  reading. 
The  point  at  w^hich  all  sounds  disappear  represents  the  diastoHc 
pressure. 


Pig.  91. — Sphygmomanometer  by  the  auscultatory  method. 

With  this  method  the  systolic  pressure  is  recorded  at  a  slightly 
higher  and  the  diastolic  pressure  at  a  lower  reading  than  by  the  pal- 
pation method,  and  as  a  result  the  pulse  pressure  will  be  also  higher. 

Variations  of  Blood-pressure  in  Disease.^ — Pain  of  all  kinds 
causes  an  increase  in  the  peripheral  resistance,  and  a  rise  in  pressure. 
Thus,  in  conditions  attended  with  severe  pain,  as  in  acute  biliary  or 
renal  colic,  during  labor,  in  acute  peritonitis,  etc.,  the  blood-pressure 
is  elevated.  If,  however,  the  patient  is  already  in  a  weakened  state  or 
is  suffering  from  shock,  the  addition  of  pain  may  cause  a  fall  in 
pressure. 

*  For  a  complete  exposition  of  this  phase  of  the  subject  the  reader  is  referred  to 
Janeway's  "Clinical  Study  of  Blood-pressure." 


SPHYGMOMANOMETRY 


117 


Wasting  diseases,  or  cachetic  conditions,  as  cancer,  tuberculosis, 
etc.,  are  as  a  rule  accompanied  by  low  pressure.  In  tuberculosis,  if 
the  pressure  is  normal  or  increased,  it  is  looked  upon  as  a  good  prog- 
nostic sign. 

In  infectious  diseases  low  pressure  is  the  rule.  In  typhoid  fever  a 
rapid  drop  is  indicative  of  hemorrhage;  if  perforation  occurs,  there  is 
a  sudden  rise  in  pressure. 

Toxic  conditions,  such  as  lead  poisoning,  acute  gout,  uremia, 
eclampsia,  exophthalmic  goiter,  etc.,  are  accompanied  by  increased 
pressure  through  reflex  vasomotor  stimulation. 

Renal  Affections. — Acute  nephritis  may  or  may  not  produce  eleva- 
tion of  pressure.  The  same  is  true  of  chronic  parenchymatous  nephri- 
tis, but  in  the  chronic  interstitial  variety  high  pressure  is  the  rule.  In 
any  variety,  with  the  onset  of  uremic  symptoms,  the  blood -pressure 
rises,  but  falls  as  improvement  in  the  condition  sets  in. 

Cardiovascular  Diseases. — In  valvular  lesions  pressure  may  or 
may  not  be  elevated;  in  fact,  the  results  of  blood-pressure  observa- 
tions in  this  class  of  cases  are  too  varied  to  be  of  value.  In  primary 
myocarditis  the  blood-pressure  is  low,  but  when  secondary  to  arterial 
or  kidney  disease  it  may  be  high.  In  arteriosclerosis  the  pressure  is 
generally  elevated,  especially  with  hypertrophy  of  the  left  ventricle. 
Arteriosclerosis  may  exist,  however,  without  elevation  of  pressure, 
and,  if  cardiac  muscle  insufficiency  be  present,  the  pressure  may  be 
below  the  normal. 

Acute  Peritonitis. — In  the  early  stages,  the  pressure  is  abnormally 
high.  A  sharp  rise  may  precede  all  other  symptoms  in  the  beginning 
of  peritonitis  from  typhoid,  appendicular,  or  other  forms  of  perfora- 
tion. 

Head  or  Brain  Injuries. — Blood-pressure  is  increased  in  compres- 
sion of  the  brain  from  depressed  bone,  extra-  or  subdural  clots,  ab- 
scess, tumors,  fracture  of  the  base,  apoplexy,  etc.,  in  proportion  to  the 
degree  of  intracranial  tension.  In  acute  compression  from  hemor- 
rhage a  high  and  rising  blood-pressure  indicates  an  increase  in  the 
bleeding  and  a  progressive  failure  of  the  circulation  in  the  medulla. 
When  the  paralytic  stage  of  compression  appears,  the  pressure  falls. 
Low  pressure  is  also  found  in  concussion  of  the  brain. 

Hemorrhage. — The  loss  of  considerable  blood  results  in  a  rapid   ' 
faU  of  pressure. 

In  shock  and  collapse  a  fall  in  blood-pressure  is  uniformly  present. 
According  to  Crile,  in  shock,  the  fall  in  pressure  is  gradual,  while  the 
term  "collapse"  should  be  limited  to  those  conditions  in  which  there 


IlS  SPHYGMOMANOMETRY 

is  a  sudden  fall  in  blood-pressure  due  to  hemorrhage,  injuries  of  the 
vasomotor  centers,  or  to  cardiac  failure. 

In  Surgical  Operations. — Ether  causes  a  rise  or  else  has  no  effect; 
even  in  large  quantities,  it  rarely  causes  a  fall.  Chloroform,  on  the 
other  hand,  causes  a  fall  in  pressure.  Nitrous  oxid  as  a  rule  causes 
an  increase  in  pressure. 

Superficial  cutting  operations  cause  a  rise  through  irritation  of  the 
peripheral  nerves — irritation  of  the  larger  nerve  trunks  causing  a 
greater  rise.  Opening  the  abdominal  cavity  likewise  produces  a  rise 
followed  by  a  fall,  the  degree  depending  upon  the  length  of  exposure 
of  the  viscera  to  the  air,  the  amount  of  handling,  separation  of  adhe- 
sions, and  sponging. 

Under  local  anesthesia  alterations  in  blood-pressure  are  less 
marked  than  when  the  same  procedures  are  carried  out  under  general 
anesthesia. 


CHAPTER  IV 

TRANSFUSION   AND   THE  INJECTION  OF  HUMAN 
BLOOD   SERUM 

TRANSFUSION 

The  term  transfusion,  as  commonly  used,  is  applied  to  the  trans- 
ference of  blood  from  the  vessels  of  a  healthy  individual  (the  donor) 
to  those  of  the  patient  (the  recipient),  while  the  term  infusion  is 
restricted  to  cases  in  which  other  media  than  blood  are  so  introduced. 

There  is  good  evidence  from  records  of  cases  that  transfusion  has 
been  practised  for  many  centuries,  but  it  was  not  until  Lower,  in 
1665,  and  Denys,  in  1667,  published  their  results  that  the  operation 
was  used  to  any  great  extent.  After  this,  it  was  employed  for  such  a 
variety  of  purposes  and  so  extravagant  were  the  claims  of  its  expo- 
nents that  the  French  government  prohibited  its  use,  and  it  soon  fell 
into  disrepute.  Early  in  the  nineteenth  century  the  operation  was 
revived,  and  it  became  a  recognized  means  of  supplying  the  body  with 
fluids  to  replace  that  lost  from  excessive  hemorrhage,  notably  that 
occurring  after  childbirth. 

The  transfusion  was  either  performed  directly  by  means  of  glass 
cannulas  tied  in  the  blood-vessels  and  joined  by  rubber  tubing,  or  else 
indirectly,  the  blood  being  drawn  from  the  donor,  and,  after  first  being 
defibrinated  by  whipping,  the  serum  resulting  was  injected  into  the 
veins  of  the  recipient.  Frequently  the  blood  of  dissimilar  species, 
such  as  sheep's  blood,  was  employed.  There  were  many  accidents 
resulting  from  the  use  of  alien  blood,  and  from  the  employment  of 
transfusion  in  an  improper  class  of  cases,  to  say  nothing  of  the  dangers 
of  infection  and  of  embolism  to  which  the  patient  was  exposed  by  the 
methods  used,  so  that  the  results  were  variable  and  uncertain,  and  in 
some  cases  even  fatal. 

As  the  subject  became  more  thoroughly  studied  and  better  under- 
stood, it  was  recognized  that  the  blood  of  dissimilar  species,  through 
its  faculty  for  breaking  up  the  red  blood-corpuscles,  was  impracticable 
and  dangerous  for  the  purpose  of  introduction  into  the  human  circu- 
lation, and  that  direct  transfusion  from  artery  to  vein  or  vein  to  vein 
only  was  permissible.^     Furthermore,  it  was  contended  by  many  that 

^  Recently,  transfusion  by  the  old  method  of  aspiration  and  injection  has  been 
revived. 

119 


I20       TRANSFUSION   AND    INJECTION    OF   HUMAN   BLOOD    SERUM 

transfusion  was  a  failure  outside  of  increasing  the  volume  of  fluid  in 
the  circulation,  as  the  blood  elements  did  not  retain  their  vitality, 
and  quickly  died  in  the  vessels  of  the  receiver.  Added  to  this,  the 
uncertainty  of  blood-vessel  anastomosis  as  formerly  practised  and 
the  fact  that  transfusion  required  the  use  of  material  and  instruments 
often  difficult  to  procure  in  an  emergency,  materially  limited  the  use- 
fulness of  the  operation,  and  it  became  less  and  less  used.  Finally, 
with  the  introduction  of  infusions  of  normal  salt  solution  as  a  sub- 
stitute, transfusion  practically  became  extinct. 

During  the  past  ten  years,  largely  through  the  work  of  Carrel, 
Crile,  and  others  in  this  country,  transfusion  has  been  revived,  and 
with  the  development  of  improved  methods  of  blood-vessel  anasto- 
mosis it  has  become  a  practical  operation,  the  value  of  which  in  cer- 
tain cases  even  outside  of  hemorrhage  and  shock  seems  to  be  well 
established,  both  experimentally  and  clinically. 

Indications  and  Contraindications. — The  principal  indication  for 
transfusion  is  severe  hemorrhage.  Crile  has  shown  that  if  performed 
early  enough  it  is  a  specific  remedy.  Experimentally  he  has  suc- 
cessfully treated  every  degree  of  hemorrhage;  dogs  were  even  bled  to 
the  last  drop  that  would  flow  and  were  then  successfully  transfused. 
Transfusion  is  also  indicated  in  pathologic  hemorrhage,  where  the 
coagulability  of  the  blood  is  deficient,  as  in  hemophiha,  cholemia, 
hemorrhage  from  the  bowels,  etc.  In  these  cases  the  condition  of  the 
patient  has  been  at  least  improved  by  the  operation  and  in  most 
cases  the  hemorrhage  has  been  controlled.  Some  of  the  reported 
cases  were  transfused  more  than  once  before  permanent  improvement 
was  noted. 

For  shock,  according  to  Crile,  transfusion  is  the  best  form  of 
treatment  we  now  possess.  It  exerts  far  greater  influence  on  blood- 
pressure  than  does  saline  solution.  Both  will  raise  blood-pressure, 
but  the  latter  will  not  maintain  the  rise  in  pressure.  Transfusion, 
on  the  other  hand,  frequently  raises  the  blood-pressure  above  normal 
and  will  sustain  it  at  a  high  level  for  a  number  of  hours. 

For  illuminating-gas  poisoning,  where  chemical  changes  occur 
which  prevent  the  blood  cells  from  giving  up  carbon  dioxid  and  com- 
bining with  oxygen,  venesection  followed  by  transfusion  is  the  best 
treatment. 

In  pellagra  marked  improvement  and  some  cures  have  followed 
the  transfusion  of  blood  from  healthy  donors  or  healed  pellagrins, 
but  it  has  not  proved  as  valuable  a  remedy  in  this  disease  as  was  first 
thought.     The  beneficial  results  are  probably  due  to  an  increased 


TRANSFUSION  121 

resistance  on  the  part  of  the  patient,  due  to  the  restoration  of  the 
blood  to  a  more  normal  condition. 

At  present  the  value  of  transfusion  in  many  other  conditions,  such 
as  tuberculosis,  chronic  suppuration,  acute  infectious  diseases,  etc., 
is  still  undetermined,  and  we  are  not  as  yet  fully  informed  as  to  what 
diseases  contraindicate  its  use.  There  have  been  cases  reported  of 
fatal  hemolysis  after  transfusion  in  pernicious  anemia  and  in  obscure 
blood  diseases,  which  indicate  that  in  some  diseases,  at  least,  trans- 
fusion of  the  blood  of  similar  species  even  is  accompanied  by  danger. 
Until  we  possess  greater  knowledge  of  the  subject,  caution  should  be 
observed  against  the  indiscriminate  employment  of  transfusion. 

Tests  for  hemolysis  should  be  made  upon  the  donor  and  the  recip- 
ient whenever  possible.  Hemolysis  between  the  donor's  corpuscles 
and  the  patient's  serum  is  not  necessarily  harmful,  but  if  it  is  found 
that  there  is  reversed  hemolysis,  that  is,  if  the  donor's  serum  hemol- 
yses the  patient's  corpuscles,  another  donor  should  be  chosen.  Theo- 
retically, agglutination  of  the  red  corpuscles  and  precipitation  may 
also  occur;  though,  according  to  Crile,  in  practice  these  changes  may 
be  disregarded. 

Selection  of  the  Donor. — If  possible,  a  young  vigorous  adult 
should  be  selected  to  supply  the  blood.  The  subject  should  prefer- 
ably be  from  among  the  relatives  of  the  patient — a  close  blood  rela- 
tion, as  a  brother  or  sister,  if  possible.  It  is  essential  that  the  donor 
chosen  be  free  from  arterio-sclerosis,  organic  heart  disease,  malaria, 
syphilis,  etc.,  and  a  thorough  physical  examination,  including  a 
Wassermann  reaction,  should  be  made  to  determine  his  fitness. 

ARTERY  TO  VEIN  TRANSFUSION 

An  anastomosis  between  the  artery  of  the  donor  and  the  vein  of 
the  recipient  may  be  effected  by  means  of  the  special  tubes  of  Crile, 
or  some  of  the  modifications  of  these  tubes,  or  by  means  of  the  direct 
suture  method  of  Carrel.  Crile's  method  is  without  doubt  the  more 
rapidly  and  easily  performed  of  the  two.  It  consists  essentially  of 
slipping  the  tube  over  the  vein,  turning  the  free  end  of  the  vein  back 
over  the  outer  surface  of  the  tube,  and  then  drawing  the  artery  over 
this  venous  cuff.  By  this  method  the  intimae  of  the  vessels  are 
brought  into  apposition  and  there  is  no  foreign  substance  in  contact 
with  the  stream  of  blood,  thus  lessening  the  chance  of  thrombosis. 
Anastomosis  by  direct  suture,  while  it  brings  about  the  same  result, 
is  difficult  to  perform  except  by  one  accustomed  to  blood-vessel  su- 


122        TRANSFUSION    AND    INJECTION    OF   HUMAN   BLOOD    SERUM 

ture.  In  addition,  there  is  frequently  a  contraction  of  the  vessels 
at  the  point  of  suture,  and  thrombosis  is  more  Hkely  to  occur.  The 
operator  intending  to  perform  transfusion  should,  however,  be  famil- 
iar with  both  methods. 

Instruments. — There  will  be  required  a  scalpel,  an  ordinary  pair 
of  blunt-pointed  scissors,  a  small  pair  of  curved  scissors,  thumb  for- 
ceps, very  fine  tissue  forceps,  two  small  Crile  clamps,  mosquito  hemo- 
stats,  and  transfusion  cannulae.  If  direct  suture  is  employed,  instead 
of  the  Crile  tubes,  there  will  be  needed  several  No.  i6  cambric  needles 
and  fine  strands  of  silk  (Fig.  92).  The  silk  should  be  thoroughly 
impregnated  with  vaselin  and  should  be  threaded  into  the  needles 
before  the  operation  is  begun. 


Fig.  92. — Instruments  for  transfusion,  i,  Scalpel;  2,  thumb  forceps;  3, 
blunt-pointed  scissors;  4,  mosquito  hemostats;  5,  fine  tissue  forceps;  6,  Crile 
clamps;  7,  small  pair  of  curved  scissors;  8,  Crile  cannulas;  9,  needles  threaded  with 
fine  strands  of  silk. 


The  tube  devised  by  Crile  is  of  German  silver  and  is  provided  with 
a  small  handle  and  with  two  grooves  upon  the  outer  surface  of  the 
cannula  portion  into  which  fit  the  ligatures  holding  the  vein  and 
artery  in  place  (Fig.  94).  At  least  four  sizes  of  these  tubes  should  be 
at  hand,  and  the  largest  size  that  can  be  used  without  injury  to  the 
arterial  coats  by  undue  stretching  should  be  employed. 

To  avoid  the  necessity  of  having  several  sizes  of  cannulae  and  to 
furnish  an  instrument  that  can  be  more  easily  manipulated,  Buerger 
has  devised  a  cannula  which  is  supplied  with  a  long  handle  and  is 
made  with  a  slit  in  the  circumference  of  the  tube  so  that  it  is  possible 
to  alter  the  diameter  of  the  cannula  to  fit  the  individual  vessels  (Fig. 
95). 


TRANSFUSION 


123 


Position  of  the  Donor  and  Recipient. — The  donor  should  lie  upon 
an  operating-table  of  such  make  that  will  permit  his  head  to  be 
quickly  lowered  if  he  becomes  faint  while  the  operation  is  in  progress. 
The  recipient  is  placed  upon  a  second  table,  with  the  head  turned  in 
the  opposite  direction.  Both  tables  should  be  provided  with  cush- 
ions or  a  layer  of  pillows,  so  that  the  patients  will  be  comfortable 
during  the  operation.     Between  the  two  operating- tables  is  placed  a 


Fig.  93. — Enlarged  view  of  Crile's  clamps.     (After  Fowler.)      I,  Clamp  without 
rubbers;  2,  rubber  tubes  to  fit  on  jaws  of  clamps;  3,  clamp  applied  to  artery. 

small  square  table  upon  which  the  arms  of  the  donor  and  recipient 
rest  during  the  operation.  The  operator  is  seated  upon  a  stool  in 
front  of  this  table,  and  his  assistant  opposite  (Fig.  96). 

Asepsis. — The  strictest  asepsis  must  be  observed  during  the 
entire  operation.  The  instruments  are  boiled,  and  the  hands  of  the 
operator  are  prepared  in  the  usual  way.     The  forearms  of  the  donor 


Fig.  94. — Enlarged  view  of  Crile's  cannula. 
Fig.  95. — Buerger's  cannula. 

and  the  recipient  should  be  sterilized  by  painting  with  tincture  of 
iodin. 

Anesthesia. — The  operation  is  performed  under  local  anesthesia, 
employing  a  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  solution 
of  novocain  for  the  skin  and  a  o.i  per  cent,  cocain  solution  or  a 
0.5  per  cent,  solution  of  novocain  for  deeper  infiltration. 

Quantity  Transfused. — It  is  impossible  to  estimate  the  exact 
amount  of  blood  transfused  and  the  guides  should  be  the  condition  of 


124       TRANSFUSION   AND   INJECTION   OF   HUMAN  BLOOD    SERUM 


the  donor  and  the  recipient;  the  amount  should  also  vary  according 
to  the  condition  for  which  the  transfusion  is  performed.  Twenty 
to  forty-live  minutes'  flow  in  a  good  anastomosis  is  usually  sufficient. 
As  soon  as  the  donor  shows  signs  of  loss  of  blood — indicated  b}-  a 
gradual  pallor  about  the  nose  and  ears,  deepening  of  the  lines  of 
expression,  sighing  or  irregular  respiration,  etc. — the  transfusion 
must  be  immediately  stopped.  If  it  is  carried  too  far,  the  donor 
goes  into  a  state  of  collapse,  and  a  condition  is  produced  in  him  similar 
to  that  for  the  relief  of  which  the  operation  was  performed.  Fur- 
thermore, transfusion  of  excessive  am.ounts  of  blood  may  cause  ser- 


Upe  rating   7a hie 
J  /Lecipient~ 


0.     0 


Operating  /ahle. 
Z  jDonor 


Fig.  96. — Arrangement  of  the  operating-tables  for  a  transfusion.  (After 
Crile.)  I,  Table  for  recipient;  2,  table  for  donor;  3,  table  for  arms  of  recipient 
and  donor;  4  and  5,  stools  for  operator  and  assistant;  6,  instrument  table;  7, 
table  for  dressings,  etc. 

ious  damage  to  the  viscera  of  the  recipient,  and  even  death.  Acute 
dilatation  of  the  heart,  manifested  by  dyspnea,  cyanosis,  cough, 
pain  over  the  precordium,  and  falling  blood-pressure,  is  the  most 
frequent  sequel  to  overtransfusion.  Should  such  a  complication 
ensue,  the  transfusion  must  be  immediately  stopped,  the  patient 
should  be  placed  in  a  reverse  Trendelenburg  position  with  the  feet 
lowered,  and  external  massage  of  the  heart  (page  54)  performed  to 
assist  in  emptying  it. 

Rapidity  of  Flow. — The  rate  with  which  the  blood  flows  from  the 
donor  to  the  recipient  should  be  carefully  gauged,  for  fear  of  over- 
charging the  heart  and  producing  an  acute  cardiac  dilatation.  This 
may  be  determined  by  noting  the  strength  of  the  pulsation  in  the 
veins.  If  too  strong,  the  flow  may  be  regulated  by  partially  com- 
pressing the  lumen  of  the  artery  by  means  of  the  fingers. 


TRAXSFUSIOX 


125 


Teclinic  by  Crile's  Method. — The  radial  artery  of  the  donor  and 
any  of  the  superficial  A-eins  in  front  of  the  elbow  of  the  recipient  are 
chosen  for  making  the  anastomosis — in  a  child  the  pophteai  vein 
may  be  utilized.  Both  the  donor  and  the  recipient  are  given  1/4 
gr.  (0.0162  gm.)  of  morphin  hA-podermically  half  an  hour  before  the 
operation  unless  it  is  contraindicated. 

The  area  of  incision  is  infiltrated  T^dth  cocain,  and  about  i  1/2 
inches  (4  cm.)  of  the  radial  artery  is  exposed  and  dissected  free. 
Any  branches  are  avoided  if  possible;  if  they  cannot  be  avoided,  they 
may  be  tied  off  with  fine  silk  and  cut  close  to  the  trunk.  A  Crile 
clamp  is  gently  applied  as  high  as  possible  to  the  proximal  end  of 


Fig.  97. — Transfusion  bj'  Crile's  method.     First  step,  exposure  of  the  vein  and 
artery  with  Crile's  clamps  applied. 

the  artery,  or,  in  the  absence  of  a  special  clamp,  a  piece  of  tape 
may  be  placed  around  the  artery  and  clamped  sufficiently  tight  to 
compress  the  vessel  and  shut  ofi'  the  circulation.  The  distal  end  of 
the  artery  is  then  ligated  and  the  vessel  is  cut.  The  adventitia  is 
pulled  over  the  end  of  the  vessel  and  is  snipped  ofi'  as  clean  as  possible. 
The  field  of  operation  is  now  covered  vnth  a  compress  well  soaked 
with  hot  saline  solution.  The  vein  of  the  recipient  is  then  exposed 
in  the  same  manner,  and  about  i  i/'2  inches  (4  cm.)  of  it  is  freed  from 
the  surrounding  tissues.  The  distal  end  of  the  vein  is  ligated,  and 
to  the  proximal  end  is  applied  a  Crile  clamp  CFig.  97),  or  a  narrow 
piece  of  tape  fastened  as  described  above.  The  vessel  is  divided  and 
the  adventitia  is  snipped  off  after  pulling  it  out  over  the  end  of  the 
vessel.  A  Crile  cannula  of  appropriate  size,  held  in  an  artery  clamp, 
is  pushed  over  the  vein.  A  suture  inserted  in  the  edge  of  the  vein, 
as  shown  in  Fig.  98,  aids  in  drawing  the  latter  through  the  cannula. 
The  projecting  portion  of  the  vein  is  seized  by  three  mosquito  clamps 
and  is   turned  back   as  a  cuff  (Fig.  99),  and  is  tied  in  the  second 


126        TRANSFUSION    AND    INJECTION    OF    HUMAN   BLOOD    SERUM 

groove  of  the  cannula.  The  forearms  of  the  donor  and  the  recipient 
are  then  placed  so  that  the  hand  of  the  donor  is  directed  toward  the 
elbow  of  the  recipient.     The  cuffed  portion  of  the  vein  is  lubricated 


Fig.  98.  Fig.  99.  Fig.  100. 

Fig.  98. — Transfusion  by  Crile's  method.  (After  Crilc.)  Second  step,  draw- 
ing the  vein  through  the  cannula. 

Fig.  99. — Transfusion  by  Crile's  method.  (After  Crile.)  Third  step, 
method  of  cuffing  back  the  vein. 

Fig.  100. — Transfusion  by  Crile's  method.  (After  Crile.)  Fourth  step, 
showing  the  vein  cuffed  back  over  the  cannula  and  the  method  of  drawing  the  artery 
over  the  vein. 

with  sterile  vaselin,  three  mosquito  forceps  are  applied  to  the  edges 
of  the  artery,  and  it  is  gradually  drawn  down  over  the  cuffed  vein 
(Fig.  100)  and  is  tied  in  place  by  a  silk  ligature  which  fits  into  the 
first  groove  on  the  cannula.     The  clamp  is  removed  from  the  vein 


Figs.   101   and    102. — Transfusion   by   Crile's  method. 

anastomosis  completed. 


Fifth  step,  showing  the 


first.  The  clamp  upon  the  artery  is  then  very  gradually  opened, 
allowing  the  blood  to  flow  into  the  vein  of  the  recipient  (Figs.  loi 
and  102).     At  the  completion  of  the  operation  the  vessels  are  ligated, 


TRANSFUSION  1 27 

the  tube  is  excised,  and  the  skin  incision  is  sutured  and  dressed 
with  sterile  gauze. 

In  performing  the  operation  there  are  several  precautions  to  be 
observed.  The  vessels  to  be  anastomosed  must  be  handled  with  the 
greatest  care.  They  should  never  be  bruised  with  artery  clamps  or 
picked  up  with  toothed  forceps.  Some  difficulty  may  be  experienced 
from  retraction  of  the  vessels  when  they  are  cut.  This  may  be  over- 
come to  a  great  extent  by  keeping  them  constantly  moistened  with 
hot  saline  solution.  In  the  case  of  a  contracted  artery,  Crile  advises 
that  it  be  dilated  by  gently  inserting  a  fine  pair  of  closed  artery  clamps 
covered  with  vaselin  and  using  it  as  one  would  a  glove  stretcher. 
Care  should  be  taken  that  the  anastomosis  be  made  without  undue 
tension,  and  that  the  cannula  be  placed  accurately  in  the  long  axis 
of  the  vein  and  artery,  otherwise  the  flow  will  be  more  or  less  impeded. 


Fig.   103. — Brewer's  glass  tubes  lined  with  paraffin  for  transfusion. 

Variations  in  Technic. — Brewer  has  simplified  Crile's  method 
of  making  an  anastomosis  by  employing  long  glass  tubes  lined  with 
paraffin  (Fig.  103).  These  tubes  are  about  2  1/2  inches  (6  cm.)  long, 
and  are  made  small  at  the  end  to  be  inserted  into  the  artery  and  large 
at  the  end  over  which  the  vein  is  drawn.  Each  end  is  slightly  bul- 
bous, and  is  provided  with  a  sulcus  into  which  the  ligature  holding 
the  vessel  in  place  falls. 

The  tubes  are  thoroughly  sterilized  and  are  then  dipped  in 
melted  paraffin,  shaken  out,  and  allowed  to  cool.  The  vein  and 
artery  are  exposed  and  isolated  in  the  usual  way  and  two  Crile  clamps 
are  applied  as  shown  in  Fig.  97.  The  artery  is  drawn  over  one  end  of 
the  tube  and  is  secured  by  a  ligature.  A  longitudinal  or  a  transverse 
cut  is  made  in  the  wall  of  the  vein  (see  Fig.  118),  and,  after  loosening 
the  arterial  clamp  sufficiently  to  permit  the  tube  to  fill  with  blood, 
the  distal  end  of  the  tube  is  quickly  inserted  into  the  vein  in  the 
manner  shown  in  Fig.  119,  and  is  secured  in  place  by  a  ligature.  The 
clamps  are  then  removed  and  the  blood  is  allowed  to  flow. 


128       TRANSFUSION   AND   INJECTION    OF   HUMAN   BLOOD    SERUM 

It  is  claimed  that  the  length  of  these  tubes  and  the  ease  with 
which  they  are  inserted  into  the  vessels  render  the  operation  consider- 
ably less  difficult. 

Hartwell  {Journal  of  the  American  Medical  Association,  Jan.  23, 
1909)  has  devised  a  method  of  tranfusion  without  the  use  of  a  cannula 
by  simply  inserting  the  artery  into  the  vein.  He  describes  the 
method  as  follows:  "The  artery  and  vein  are  dissected  out,  tempo- 
rarily clamped  and  divided  in  the  usual  manner,  with  the  usual  care 
in  securing  the  small  branches.  The  adventitia  is  removed  from  each, 
but  a  small  coil  of  it  is  left  curled  up  on  the  outside  of  the  artery  about 
I  1/2  inches  (4  cm.)  from  the  cut  proximal  end.  Three  guiding 
sutures  of  fine  silk  are  then  passed  by  means  of  a  fine  needle — an 
ordinary  intestinal  needle  and  zero  silk  are  sufficiently  fine — at 
intervals  of  120  degrees  in  the  circumference  of  the  cut  end  of  the 
vein.  The  end  of  the  artery  is  greased  with  melted  sterilized  petro- 
latum.    The  mouth  of  the  vein  is  drawn  open  with  the  sutures,  and 


Fig.    104. — Levin's  transfusion  clamp. 

the  artery  is  passed  directly  into  it  for  a  distance  of  an  inch  (2.5  cm.). 
One  of  the  guiding  sutures  is  then  passed  through  the  rolled  up 
adventitia  on  the  artery,  to  hold  the  two  vessels  in  contact,  and  the 
greater  or  less  amount  of  superfluous  circumference  of  the  vein  is 
clamped  or  sutured  so  as  simply  to  approximate  the  artery  but  not 
to  constrict  it.  The  obstructing  clamps  are  removed,  and  the  blood 
current  is  allowed  to  flow." 

Levin  {Annals  of  Surgery,  ]March,  1909)  describes  a  clamp  form 
of  transfusion  cannula.  This  instrument  (Fig.  104)  is  made  in  the 
form  of  an  artery  clamp  with  a  small  cannula  attached  to  the  tip 
of  each  blade.  Upon  the  free  edge  of  each  cannula  are  placed  four 
small  pin  points,  and  upon  the  outer  surface  are  four  grooves  into 
which  the  pins  fit  when  the  two  cannulas  are  in  contact. 

To  perform  an  anastomosis  with  this  instrument  the  two  halves 
of  the  instrument  are  separated.  The  cut  vein  is  passed  through  one 
cannula  and  its  wall  is  hooked  on  the  pins.  The  artery  is  treated  in 
a  similar  manner,  and  then  both  halves  of  the  instrument  are  united 
and  clamped. 


TRANSFUSION  1 29 

Elsberg  {Journal  of  the  American  Medical  Association,  March 
13,  1909)  describes  a  very  practical  cannula  that  does  away  with  the 
necessity  for  the  Crile  clamps.  His  method  of  performing  the  anasto- 
mosis differs  from  the  Crile  method  in  several  points.  "The  cannula 
(Fig.  105)  is  built  on  the  principle  of  a  monkey  wrench,  and  can  be 
enlarged  or  narrowed  to  any  size  desired  by  means  of  a  screw  at  its 
end.  The  smallest  lumen  obtainable  is  about  equal  to  that  of  the 
smallest  Crile  cannula,  and  the  largest  greater  than  the  lumen  of  any 
radial  artery.  The  instrument  is  cone-shaped  at  its  tip,  a  short  dis- 
tance from  which  is  a  ridge  with  four  small  pin  points  which  are 
directed  backward.  The  lumen  of  the  cannula  at  its  base  is  larger 
than  at  its  tip." 

In  using  this  instrument,  after  first  exposing  and  separating  the 
artery  from  the  surrounding  tissues  in  the  usual  manner,  the  cannula 


Fig.   105. — Elsberg's  transfusion  cannula. 

is  widely  opened  and  is  placed  around  the  artery  before  the  latter  is 
cut.  The  cannula  is  then  screwed  together,  thereby  shutting  off  the 
arterial  flow.  The  distal  end  of  the  artery  is  next  ligated  at  about 
1/2  inch  (i  cm.)  from  the  end  of  the  cannula,  and  three  fine  silk  trac- 
tion sutures  or  small  tenacula  are  passed  through  the  artery  at  equi- 
distant points  on  its  circumference  a  short  distance  from  the  ligature. 
The  artery  is  then  cut  close  to  the  ligature,  and  the  end  is  cuffed  back 
by  drawing  upon  the  traction  stitches  or  tenacula  and  is  caught  in  the 
teeth  upon  the  clamp.  The  vein  of  the  recipient  is  then  exposed  and 
two  ligatures  are  applied,  the  distal  one  being  tied  (see  Fig.  117). 
The  vein  is  opened  by  means  of  a  small  transverse  slit  in  the  same 
manner  as  for  an  intravenous  infusion  (see  Fig.  118),  and  the  cannula 
with  the  cuffed  artery  is  inserted  into  the  vein  and  tied  securely  in 
place  by  means  of  the  loose  ligature.  The  cannula  is  then  screwed 
open  and  the  blood  is  allowed  to  flow,  the  rapidity  of  flow  being  con- 
trolled by  the  extent  to  which  the  cannula  is  opened. 

Technic  by  Carrel's  Suture.— Under  local  anesthesia  the  radial 
artery  of  the  donor  and  the  median  basilic  vein  of  the  recipient  are 
dissected  free  for  a  distance  of  i  1/2  inches  (4  cm.),  and  any  small 
branches  are  tied  off  with  fine  silk  close  to  the  main  trunk.  A  small 
Crile  clamp  is  applied  to  the  proximal  portion  of  the  artery  as  near  as 


130        TRANSFUSION    AND    INJECTION    OF    HUMAN   BLOOD    SERUM 

possible  to  the  upper  limit  of  the  incision,  and  the  distal  end  of  the 
vessel  is  tied  off.  The  artery  is  then  cut  close  to  the  distal  ligature 
and  the  adventitia  is  drawn  down  over  the  end  of  the  vessel  and 
trimmed  off.  The  field  of  operation  is  then  covered  by  a  pad  mois- 
tened in  saline  solution,  while  the  attention  of  the  operator  is  directed 


Fig.   106.  Fig.  107. 

Fig.  106. — Transfusion  by  Carrel's  suture.  (After  Carrel.)  First  step,  show- 
ing the  method  of  inserting  the  three  traction  sutures. 

Fig.  107. — Transfusion  by  Carrel's  suture.  (After  Carrel.)  Second  step,  the 
three  traction  sutures  in  place. 

to  preparing  the  vein.  The  extreme  distal  end  of  the  vein  is  tied  off 
with  a  ligature,  a  Crile  clamp  is  applied  to  the  proximal  portion,  and 
the  vessel  is  severed  close  to  the  distal  ligature  (see  Fig.  97).  The 
end  of  the  vein  is  then  trimmed  of  its  adventitia,  as  was  the  artery. 
The  arms  of  the  donor  and  the  recipient  are  placed  near  together  upon 


Fig.   108.  Fig.  109. 

Fig.  108. — Transfusion  by  Carrel's  suture.  (After  Carrel.)  Third  step, 
showing  the  method  of  suturing  the  artery  and  vein. 

Fig.  109.— Transfusion  by  Carrel's  suture..  (After  Carrel.)  Fourth  step, 
the  anastomosis  completed. 

a  small  table,  so  that  the  vessels  may  be  brought  together  without 
tension,  the  hand  of  the  donor  pointing  toward  the  elbow  of  the 
recipient.  The  ends  of  the  two  vessels  are  then  sutured  together  as 
follows: 


VEIN    TO   VEIN    TRANSFUSION  I3I 

The  needle,  threaded  with  a  fine  strand  of  silk  impregnated  with 
vaselin,  is  passed  through  the  wall  of  the  artery  from  without  in  and 
through  the  wall  of  the  vein  (Fig.  io6),  and  the  two  ends  of  the  suture 
are  tied  and  left  long,  to  serve  as  a  traction  stitch.  Two  other  sutures 
are  similarly  placed  at  such  points  that  the  circumference  of  the 
vessels  is  divided  into  three  equal  parts  (Fig.  107).  Two  of  these 
traction  sutures  are  made  taut,  and  the  walls  of  the  vessels  between 
them  are  readily  sutured.  A  continuous  stitch  is  employed  for  this, 
the  stitches  being  placed  near  the  edges  of  the  vessels  and  close  to- 
gether to  prevent  leakage  (Fig.  108).  Before  performing  this  sutur- 
ing a  clamp  should  be  attached  to  the  third  traction  stitch  and  should 
be  allowed  to  hang  from  below  so  as  to  open  the  lumen  of  the  vessel 
and  thus  avoid  including  other  portions  of  the  intima  in  the  suture. 
As  soon  as  one-third  of  the  vessels  is  united,  the  next  two  traction 
stitches  are  made  taut  and  another  third  is  sutured,  the  clamp  being 
again  shifted  to  the  under  stay.  The  remaining  third  is  united  in 
precisely  the  same  manner,  thus  completing  the  suturing  around  the 
entire  circumference  of  the  two  vessels  (Fig.  109).  The  clamp  upon 
the  vein  is  removed  first,  and  then  the  arterial  clamp  is  slowly  un- 
screwed, allowing  the  blood  to  gradually  flow  from  one  vessel  into 
the  other.  If  the  sutures  are  properly  applied,  there  should  be  but 
little,  if  any,  leakage  at  the  line  of  union. 

VEIN  TO  VEIN   TRANSFUSION 

In  place  of  the  artery  to  vein  method,  vein  to  vein  transfusion 
has  been  advocated  by  Dorrance  and  Ginsburg  as  being  simpler  and 
easier  to  perform  than  artery  to  vein  anastomosis  on  account  of  the 
superficial  location  of  the  vessels.  Another  advantage  claimed  for 
this  method  is  that  the  flow  of  blood  being  slower,  the  danger  of  pro- 
ducing acute  dilatation  of  the  heart  is  avoided.  Vein  to  vein 
anastomosis  may  be  performed  by  the  direct  suture  method  of  Carrel 
or  by  means  of  any  of  the  mechanical  devices  already  described  under 
artery  to  vein  transfusion.  Fauntleroy  has  devised  paraffin-coated 
curved  glass  tubes,  somewhat  similar  to  those  of  Brewer,  by  the  use 
of  which  vein  to  vein  transfusion  is  very  much  simplified. 

Technic. — The  arm  of  the  donor  is  constricted  immediately  below 
the  axilla  with  a  tourniquet  applied  with  just  sufiicient  tension  to 
distend  the  superficial  veins  but  not  tight  enough  to  obstruct  the 
arterial  flow.  This  causes  the  superficial  veins  to  dilate  and  stand 
out  prominently.     The  veins  of  the  recipient  are  similarly  treated. 


132        TRANSFUSION    AND    INJECTION    OF    HUMAN   BLOOD    SERUM 

Under  infiltration  anesthesia  the  median  cephalic  or  the  median 
basilic  veins  of  both  the  donor  and  the  recipient  are  exposed  through 
a  3-inch  (7.5  cm.)  incision  and  an  anastomosis  between  the  distal  end 
of  the  donor's  vein  and  the  proximal  end  of  the  recipient's  vein  is 
made  by  some  of  the  methods  previously  described  under  artery  to 
vein  anastomosis.  As  soon  as  the  anastomosis  is  completed  the 
tourniquet  is  removed  from  the  recipient's  arm  while  that  upon  the 
donor's  arm  is  simply  loosened,  being  left  with  sufficient  tension  to  pro- 
duce a  well-marked  hyperemia  and  an  increase  in  the  venous  pres- 
sure. In  this  way  there  is  enough  pressure  created  in  the  vein  of  the 
donor  to  cause  the  blood  to  flow  freely  into  the  vein  of  the  recipient. 
By  this  method  the  flow  of  blood  will  be  less  rapid  than  in  an  artery 
to  vein  anastomosis  and  the  transfusion  will  need  to  be  continued 
over  a  longer  period  of  time. 

INJECTIONS  OF  HUMAN  BLOOD  SERUM 

For  manv  vears  it  has  been  known  that  blood  serum  contained 
some  agent  that  hastened  the  coagulation  of  blood.  In  1882  Hayem 
estabhshed  this  fact  while  performing  experiments  with  different 
sera  to  determine  their  effect  on  coagulation.  It  is  only,  however, 
since  Weil  in  1905  published  the  results  of  his  work  along  this  line 
that  the  injection  of  fresh  animal  and  human  serum  has  become  gen- 
erally recognized  as  a  method  of  value  for  the  prevention  and  control 
of  certain  forms  of  hemorrhage,  such  as  is  seen  in  hemophilia,  chole- 
mia,  and  purpuric  conditions  supposed  to  be  dependent  upon  defi- 
cient coagulability  of  the  blood.  ]More  recently  Welch  of  New  York 
has  shown  that  the  subcutaneous  injection  of  human  blood  serum 
is  almost  a  specific  remedy  for  the  treatment  of  hemophilia  neona- 
torum; from  the  rapid  gain  in  weight  after  its  use  he  also  considers 
it  a  most  efficient  food  for  premature  and  malnourished  infants. 
Blood  serum  is,  likewise,  claimed  to  be  of  value  in  septic  conditions 
on  account  of  its  bactericidal  action. 

Wbile  horse  serum,  rabbit  serum,  and  human  serum  have  all 
been  employed  in  these  cases  of  pathologic  hemorrhage,  the  latter 
should  always  be  used  in  preference.  With  animal  sera  there  is 
danger  of  producing  serum  sickness  and  anaphylaxis,  especially  where 
repeated  injections  are  made,  but  this  is  apparently  not  the  case 
with  human  serum. 

It  should  be  remembered  that,  while  the  injection  of  human  serum 
is  an  efficient  method  of  controlling  pathologic  hemorrhages,  it  does 


INJECTIONS    OF   HUMAN  BLOOD    SERUM 


133 


not,  of  course,  replace  the  cellular  elements  lost  through  excessive 
bleeding.  In  such  cases,  where  the  cellular  elements  are  greatly 
diminished,  transfusion  is  indicated. 

Apparatus. — The  apparatus  for  collecting  the  blood,  described  by 
Welch  {American  Journal  of  Medical  Sciences,  June,  19 10),  consists, 
of  an  Erlenmeyer  flask  stoppered  with  a  rubber  cork  through  which 
are  two  perforations.  Through  one  is  fitted  a  U-shaped  tube,  to  the 
outer  end  of  which  is  attached  a  short  aspirating  needle  of  No.  19 
caliber  by  means  of  a  rubber  tubing.  The  needle  is  cotton  plugged 
in  a  small  test-tube  in  which  it  is  sterilized. 
Through  the  other  perforation  is  inserted  a 
fusiform  glass  tube  containing  cotton  to  pre- 
vent contaminating  the  contents  of  the  flask. 
Upon  the  end  of  this  tube  is  placed  a  small 
suction  tube  for  drawing  the  blood  into  the 
flask  (Fig.  no). 

A  30  to  60  c.c.  (i  to  2  ounces)  glass  syringe 
with  a  glass  piston  should  be  provided  for  in- 
jecting the  serum. 

Selection  of  Donor. — Preferably  young 
adults  from  among  the  relatives  of  the  patient 
should  be  selected.  The  donors,  of  course, 
must  be  free  from  any  constitutional  or  other 
disease,  and  a  thorough  physical  examination, 
including  a  Wassermann  test,  should  be  made 
to  determine  their  fitness. 

Dosage. — In  hemophilia  neonatorum  Welch 
advises  that  i  ounce  (30  c.c.)  of  serum  be  given 
twice  a  day  to  moderate  bleeders  and,  if  the  bleeding  is  excessive, 
that  it  be  given  every  four  hours  until  the  bleeding  is  under  control. 

As  a  preventive  of  postoperative  hemorrhage  in  chronic  jaundice, 
Willy  Meyer  advises  that  i  to  2  ounces  (30  to  60  c.c.)  of  serum  be 
administered  three  times  a  da,y  beginning  two  days  before  the  opera- 
tion and  continuing  for  forty-eight  to  seventy- two  hours  afterward. 

Site  of  Injection. — The  serum  is  injected  subcutaneously  in  the 
loose  tissues  of  the  axilla  or  in  the  subcutaneous  tissues  of  the  abdo- 
men on  either  side  of  the  umbilicus.  In  cases  of  great  urgency  it  may 
be  given  intravenously. 

Asepsis. — The  apparatus  for  collecting  the  blood  and  the  syringe 
for  injecting  the  serum  should  be  sterilized,  the  operator's  hands 
should  be  cleansed  as  for  any  operation,  and  the  arm  of  the  donor 


Fig.  1 10. — Welch's 
apparatus  for  collect- 
ing blood  serum. 


134        TRANSFUSION    AND    INJECTION    OF    HUMAN   BLOOD    SERUM 

and  the  site  of  injection  are  sterilized  by  painting  with  tincture  of 
iodin. 

Technic. — To  collect  the  blood,  a  tourniquet  is  first  placed  about 
the  arm  of  the  donor  with  sufficient  tension  to  make  the  veins  stand 
out  prominently.  One  of  the  veins  at  the  bend  of  the  elbow — prefer- 
ably the  median  basilic — is  then  identified  and  the  needle  of  the 
collecting  apparatus  is  thrust  into  it,  holding  the  needle  almost  paral- 
lel with  the  skin  surface.  About  lo  ounces  (300  c.c.)  of  blood  is  then 
drawn  into  the  flask,  which  is  promptly  stoppered  with  a  sterile  plug 
of  cotton.  The  flask  is  then  placed  in  a  slanting  position  until  the 
serum  has  formed.  It  usually  takes  four  to  six  hours  for  all  the  serum 
to  separate.  When  this  has  taken  place,  the  serum  is  transferred 
to  a  sterile  flask  and  is  placed  on  ice  until  used. 

The  technic  of  injecting  the  serum  is  as  follows:  The  neck  of  the 
flask  is  sterilized,  and  the  desired  quantity  of  serum  is  drawn  into 
the  syringe.  Care  should  be  taken  to  see  that  all  the  air  is  ex- 
pelled from  the  syringe.  A  fold  of  skin  in  the  region  decided  upon 
for  making  the  injection  is  then  raised  up  between  the  thumb  and 
forefinger  of  the  left  hand,  and,  with  the  right  hand  the  needle  is 
quickly  thrust  into  the  subcutaneous  tissues  at  the  base  of  this  fold 
of  skin.  The  serum  is  injected  slowly,  and  the  resulting  swelling 
is  very  gently  massaged  until  the  serum  is  all  absorbed.  After 
withdrawal  of  the  needle,  the  point  of  puncture  is  sealed  with 
collodion  and  cotton.  Usually  within  twenty-four  of  forty-eight 
hours  after  beginning  the  injections  the  bleeding  will  be  controlled. 


CHAPTER  V 
INFUSIONS  OF  PHYSIOLOGICAL  SALT  SOLUTION 

The  administration  of  physiological  salt  solution  was  originally 
introduced  as  a  substitute  for  transfusion  of  blood  in  the  treatment 
of  hemorrhage  on  account  of  the  numerous  risks  that  attended  the 
latter  operation  as  formerly  performed,  and  the  difficulty  of  obtain- 
ing a  suitable  donor  when  most  needed.  The  technic  of  direct  blood 
transfusion  has,  however,  been  wonderfully  perfected,  and  it  can 
now  be  said  to  be  an  operation  without  danger  if  employed  with 
proper  precautions;  but,  notwithstanding  this  and  the  fact  that  no 
media  has  been  found  as  efficient  as  blood  in  making  up  the  loss 
from  a  severe  hemorrhage,  the  infusion  of  salt  solution  is  employed 
in  preference  to  transfusion  in  the  great  majority  of  cases.  This 
may  be  readily  understood  when  we  consider  that  the  methods  of 
administering  salt  solution  can  be  carried  out  on  short  notice,  that 
they  require  but  little  preparation,  that  they  are  marked  by  sim- 
plicity in  technic,  and  that  they  are  within  the  reach  of  all;  on 
the  other  hand,  transfusion  becomes  a  formidable  operation  in 
comp  arison. 

Salt  solution  may  be  introduced  into  the  circulation  through  a 
vein  (intravenous  infusion),  through  an  artery  (intraarterial  infu- 
sion), through  the  subcutaneous  tissues  (hypodermoclysis),  and  by 
way  of  the  bowel  (rectal  infusion). 

Indications. — The  use  of  physiological  salt  solution  is  indicated 
in  the  following  conditions: 

(i)  In  collapse  following  severe  hemorrhage  to  replace  the  cir- 
culating fluid,  thus  giving  the  heart  a  volume  of  fluid  to  contract 
upon  and  raising  blood-pressure.  Salt  solution,  however,  cannot 
replace  the  cellular  constituents  of  the  blood,  and  in  the  severest 
grades  of  hemorrhage,  when  the  number  of  oxygen-carrying  red  cells 
falls  below  a  certain  point,  the  injection  of  fluids  into  the  circulation 
will  not  avail — only  the  transfusion  of  blood  can  avert  a  fatal  issue 
in  such  cases. 

(2)  In  the  prophylaxis  and  treatment  of  mild  surgical  shock,  for 
the  purpose  of  restoring  heat  to  the  body  and  raising  arterial  tension. 
As  shown  by  Crile,  however,  in  severe  shock,  unless  due  to  hemor- 

135 


136  INFUSIONS    OF    PHYSIOLOGICAL    SALT    SOLUTION 

rhagc,  the  rise  of  blood-pressure  is  so  temporary  that  the  first  benefits 
derived  from  the  infusion  are  not  maintained.  In  such  cases,  the 
combination  with  the  salt  solution  of  drugs  which  raise  blood-pressure, 
such  as  adrenalin  chlorid,  is  followed  by  more  marked  and  beneficial 
results.  For  a  single  infusion,  10  to  30  Tn,(o.6  to  2  c.c.)  of  the  i  to 
1000  solution  of  adrenalin  chlorid  may  be  added  to  a  pint  (500  c.c.) 
of  salt  solution,  or  the  adrenalin  may  be  administered  by  thrusting 
a  hypodermic  needle  into  the  rubber  tubing  near  the  cannula  and 
injecting  the  drug  as  the  solution  flows  into  the  vein. 

(3)  To  increase  the  fluids  in  the  tissues  where  there  is  deficient 
absorption  of  food,  as  in  excessive  vomiting,  peritonitis,  etc.,  or  to 
replace  the  fluids  lost  through  purging,  as  in  dysentery  and  cholera. 
The  administration  of  salt  solution  may  also  be  used  to  advantage 
before  undertaking  operations  upon  poorly  nourished  individuals. 

(4)  For  its  stimulating  effects  and  the  production  of  a  rapid 
elimination  of  impurities  from  the  body  by  causing  diuresis,  saline 
infusion  is  indicated  in  suppression  of  urine,  uremia,  diabetic  coma, 
eclampsia,  septicemia,  various  forms  of  toxemia,  and  in  poisoning 
from  carbonic  acid  gas,  illuminating  gas,  etc. 

(5)  For  the  purpose  of  relieving  postoperative  thirst. 

The  administration  of  saline  solution  is  contraindicated  in  ad- 
vanced dropsy,  pulmonary  edema,  or  marked  cardiac  insufficiency. 

Preparation  of  the  Solution. — To  be  exact,  normal  physiological 
salt  solution  that  is  isotonic  with  the  blood,  consists  of  nine  parts 
sodium  chlorid  to  one-thousand  parts  of  water.  A  variation  in  the 
strength  of  the  solution  between  0.6  per  cent,  and  0.9  per  cent,  is 
permissible,  however,  and  in  practice  the  solution  is  generally  made 
up  in  the  strength  of  0.7  per  cent. — roughly,  i  dram  (4  gm.)  of  chem- 
ically pure  sodium  chlorid  to  a  pint  (500  c.c.)  of  distilled  water.  It 
is  of  the  utmost  importance  that  the  solution  be  accurately  made, 
and  it  should  not  vary  much  from  this  strength  of  seven  parts  per 
thousand,  as  solutions  not  isotonic  with  the  blood  produce  certain 
untoward  changes  in  the  corpuscles.  It  is  the  opinion  of  Mummery 
that  symptoms,  such  as  chills  and  sweating,  which  are  sometimes 
seen  after  intravenous  infusions,  are  due  to  the  incorrect  chemical 
composition  of  the  fluid  employed.  Carelessness  in  this  respect, 
as  well  as  disregard  of  the  proper  temperature  of  the  solution,  are 
without  doubt  also  responsible  for  many  of  the  cases  of  reported 
sloughing  of  the  tissues  after  subcutaneous  infusion. 

A  convenient  method  of  keeping  the  salt  solution  ready  for  use 
is  to  have  a  sterilized  and  very  concentrated  solution  put  up  in 


INFUSIONS    OF    PHYSIOLOGICAL    SALT    SOLUTION  I37 

hermetically  sealed  tubes,  in  such  a  strength  that  the  contents  of 
one  tube  emptied  into  a  quart  <  looo  c.c.j  of  sterile  water  gives  a 
normal  salt  solution  (Fig.  in).  In  hospital  practice  it  is  customary 
to  keep  the  solution  in  stock  bottles  ready  for  use.  The  solution  is 
made  up  in  the  proper  strength  from  sterile  salt  dissolved  in  sterile 
water,  and  is  then  prepared  as  follows.^  "■  Filter  into  flasks  (sterilized 
by  washing  with  bichlorid  solution,  then  rinsing  with  sterile  water) 
stoppered  with  nonabsorbent  cotton,  sterilize  for  one  hour  for  three 
successive  days  at  a  temperature  of  220°  F.,  and  cover  the  cotton 
stoppers  wdth  a  small  square  of  rubber  tissue  held  in  place  by  a 
rubber  band.  Wlien  needed,  place  the  flask  in  a  deep  basin  filled 
with  hot  water  until  raised  to  the  proper  temperature."'     A  more 


Fig.    III. — A  tube  of  concentrated  sterile  salt  solution. 

convenient  method  of  bringing  the  solution  to  the  required  tempera- 
ture W'hen  needed  for  use  is  to  have  at  hand  very  hot  and  cold  salt 
solutions  in  separate  flasks.  The  solution  may  be  quickly  heated 
by  placing  the  flasks,  surrounded  by  water  to  their  necks,  in  a  steril- 
izer or  a  deep  basin,  and  bringing  the  water  to  the  boiling-point. 
Some  of  the  cold  solution  is  poured  into  the  reservoir  first,  and  suffi- 
cient of  the  hot  solution  is  then  added  to  bring  the  contents  of  the 
reservoir  to  the  proper  temperature. 

Other  Solutions  Employed. — Some  operators  prefer  to  employ 
artificial  sera  prepared  according  to  certain  fromul^,  the  object  being 
to  obtain  a  solution  as  nearly  identical  to  the  blood  serum  as  possible. 
Some  of  those  most  frequently  used  are  as  follows: 

Hare's  formula:  (Approximately.) 


Calcium  chlorid, 

0.25  gm. 

gr.  iv. 

Potassium  chlorid, 

0. 10  gm. 

gr.  I  12 

Sodium  chlorid, 

9        gm. 

dr.  2  1,4 

Distilled  water, 

1000        c.c. 

qt.  i. 

Ringer's  formula: 

Potassium  chlorid, 

0.25  gm. 

gr.  iv. 

Calcium  chlorid, 

0.3    gm. 

gr.  4  1/2 

Sodium  chlorid, 

7         gm. 

dr.  I  2/3 

Distilled  water, 

1000        c.c. 

qt.  i. 

1  Fowler.     "The  Operating-room 

and  the  Patient." 

138 


INFUSIONS   OF   PHYSIOLOGICAL   SALT   SOLUTION 


Locke  s  formula: 

Calcium  chlorid, 
Potassium  chlorid, 
Sodium  bicarbonate, 
Glucose, 
Sodium  chlorid. 
Distilled  water, 

Szumann's  formula: 

Sodium  chlorid, 
Sodium  carbonate. 
Distilled  water 


o 

2 

gm. 

gr.  HI. 

o 

42 

gm. 

gr.  VI. 

o. 

3 

gm. 

gr.  4  1/2 

I 

gm. 

gr.  XV. 

9 

gm. 

dr.  2  1/4 

I  coo 

c.c. 

qt.  i. 

6 

gm. 

dr.  I  12 

I 

gm. 

gr.  XV. 

I  coo 

c.c. 

qt.  i. 

INTRAVENOUS  INFUSION 

The  introduction  of  salt  solution  directly  into  a  vein  assures  us  of 
its  immediate  entrance  into  the  circulation  and  the  certainty  of  its 


Fig.   112. — Apparatus  for  giving  an  intravenous  infusion.     (Ashton.) 

absorption.  The  intravenous  method  is  thus  indicated  in  any  of  the 
conditions  previously  mentioned  where  there  is  necessity  for  great 
haste  and  a  prompt  response  to  the  treatment.  The  advantages  of 
this  method  of  infusion  are  pointed  out  by  Matas  as  being  almost 
unrestricted  in  possibilities  in  regard  to  quantity,  comparatively 
much  less  painful  than  the  subcutaneous  method,  and  requiring  the 
simplest  and  most  readily  improvised  apparatus. 


INTRAVENOUS    INFUSION 


139 


Apparatus. — There  should  be  provided  a  thermometer,  a  gradu- 
ated glass  irrigating  jar,  about  6  feet  (180  cm.)  of  rubber  tubing, 
1/4  inch  (6  mm.)  in  diameter,  and  a  blunt-pointed  metal  infusion 
cannula  (Fig.  112).  In  addition,  a  constrictor  for  the  arm,  a  gauze 
compress,  and  a  bandage  will  be  required. 

In  an  emergency,  a  fountain  syringe  or  a  large  funnel  will  answer 
for  the  reservoir,  and  the  glass  tube  of  a  medicine  dropper  will  take 
the  place  of  a  cannula. 

Instruments. — The  operator  will  require  a  scalpel,  a  pair  of  blunt- 
pointed  scissors,  mouse-toothed  thumb  forceps,  an  aneurysm  needle, 
a  needle  holder,  two  curved  needles  with  a  cutting  edge,  and  No.  2 
plain  catgut  (Fig.  113). 


^ 


i  ^^  o  ^  4 

Fig.   113. — Instruments     for     intravenous     infusion,      i, 
pointed    scissors;     3,    thumb   forceps;     4,    aneurysm    needle; 
curved  needles;  7,  No.  2  plain  catgut. 


7 
Scalpel;  2,     blunt- 
5,    needle    holder;    6, 


Asepsis. — Strict  asepsis  should  be  observed.  The  instruments 
and  apparatus  should  be  boiled,  the  thermometer  should  be  immersed 
in  a  I  to  500  solution  of  bichlorid  of  mercury  for  ten  minutes,  and  then 
rinsed  in  sterile  water,  and  the  operator's  hands  should  be  as  carefully 
scrubbed  as  for  any  operation. 

Temperature  of  Solution. — Most  operators  advise  that  the  solu- 
tion be  administered  at  a  temperature  of  a  few  degrees  above  that 
of  normal  blood,  i.e.,  at  about  105°  F.  (41°  C).  The  stimulating 
effect  of  heat  upon  the  circulation,  however,  should  not  be  lost 
sight  of,  and,  when  such  an  action  is  desired,  the  solution  may  be 


140 


INFUSIONS    OF   PHYSIOLOGICAL    SALT   SOLUTON 


used  at  a  tempearture  of  115°  to  118°  F.  (46°  to  48°  C.)  without 
harmful  effects.  It  should  be  borne  in  mind  that  there  will  be  some 
loss  of  heat  while  the  solution  is  flowing  from  the  reservoir.  For 
this  reason,  the  fluid  in  the  reservoir  should  be  kept  at  a  temperature 
of  from  2°  to  3°  higher  than  the  temperature  at  which  it  is  wished 
to  give  the  infusion. 

It  is  of  the  greatest  importance  that  the  solution  be  introduced 
into  the  body  at  a  uniform  temperature  throughout  the  entire  opera- 
tion. To  insure  this,  a  thermometer  is  kept 
in  the  solution  continuously.  By  watching 
the  thermometer  and  adding  hot  solution 
from  time  to  time,  as  that  in  the  reservoir 
cools,  a  uniform  temperature  may  be 
maintained. 

Rapidity  of  Flow. — The  speed  of  the 
flow  may  be  regulated  by  raising  or  lower- 
ing the  reservoir,  or  compressing  the  rub- 
ber tube.  The  rate  of  flow  should  be 
about  one  pint  (500  c.c.)  in  five  to  ten 
minutes.  It  should  be  remembered  that  the 
weaker  tJie  action  of  the  heart  the  slower  must 
the  fluid  be  introduced.  Acute  dilatation  of 
the  heart  may  be  produced  by  disregard  of 
this  caution.  Furthermore,  if  the  solution 
enters  the  circulation  too  rapidly,  the  fluid 
that  is  driven  from  the  heart  to  the  lungs 
may  consist  of  pure  salt  solution,  and  signs 
of  imperfect  oxygenation  of  the  blood  with 
embarrassed  respiration  and  restlessness  will 
follow.  If  such  symptoms  appear,  the  in- 
fusion must  be  discontinued  until  the  dan- 
gerous signs  have  passed. 

Quantity  Given. — It  has  been  shown  that  only  a  certain  amount  of 
the  solution  will  be  retained  in  the  circulation;  after  a  time  it  escapes 
into  the  tissues  and  produces  edema.  Hence  there  is  no  object  in 
infusing  enormous  quantities.  The  average  amount  administered 
at  a  time  varies  from  one  pint  (500  c.c.)  to  three  pints  (1500  c.c), 
depending  on  the  case,  but  larger  quantities  may  be  required  in  cases 
of  severe  hemorrhage,  or  after  venesection.  The  operator  will  be 
guided  as  to  the  requisite  quantity  chiefly  by  the  return  of  the  pulse, 
the  increase  in  its  volume,  and  by  the  improvement  in  the  color  of 


Fig.  114. — The  super- 
ficial veins  of  the  forearm. 
(Ashton.) 


IXTR-WEXOUS    INFUSION 


141 


the  patient's  skin.  In  severe  cases  it  may  be  advisable  to  repeat  the 
infusion  two  or  three  times  within  twenty-four  hours  rather  than  to 
infuse  an  enormous  quantity  at  one  time. 

Site  of  Operation. — One  of  the  most  prominent  veins  at  the  bend 
of  the  elbow  is  usually  chosen  (Fig.  114),  preferably  the  median 
basilic  which  runs  across  the  bend  of  the  elbow  from  without  inward.^ 
At  times  a  vein  exposed  in  the  course  of  an  operation  may  be  con- 
veniently utilized. 

Preparation  of  the  Patient. — All  clothing  should  be  removed  from 
the  area  selected  for  the  infusion,  and  that  about  the  axilla  loosened 


Fig.   115. — Showing  the  application  of  the  bandage  to  the  arm  to  constrict   the 

veins,      (Ashton.) 

if  the  arm  is  chosen  for  the  infusion.  The  bend  of  the  elbow  is 
shaved,  if  necessary,  and  is  then  painted  with  tincture  of  iodin.  A 
sterile  bandage  is  tightly  wrapped  above  the  elbow  to  compress  the 
veins  and  make  them  more  prominent  (Fig.  115).  If  the  circulation 
is  very  feeble,  even  this  expedient  may  fail  to  make  the  veins  stand 
out  conspicuously. 


1  Dawbarn  advises  that  the  infusion  be  performed  through  the  internal  saphen- 
ous vein  at  a  point  anywhere  above  the  ankle,  claiming  (i)  that  it  is  as  large  or 
larger  than  the  veins  at  the  bend  of  the  elbow;  (2)  that  there  are  no  important 
structures  near  by  to  be  injured  by  a  careless  operator;  (3)  that  the  scar  is  unob- 
jectionable; and  (4)  that  the  assistants  performing  the  operation  will  usually 
interfere  less  with  the  operating  surgeon  than  if  the  arm  is  used. 


142 


INFUSIONS    OF    PHYSIOLOGICAL    SALT    SOLUTION 


Anesthesia. — Anesthesia  of  the  skin  is  obtained  by  infiltration  at 
the  site  of  incision  with  a  0.2  per  cent,  solution  of  cocain  freshly 
prepared  or  a  i  per  cent,  solution  of  novocain,  or  by  freezing  with 
ethyl  chlorid  or  a  piece  of  ice  dipped  in  salt. 

Technic. — With  the  forearm  supinated,  a  transverse  incision  is 
made  over  the  median  basilic  vein  (Fig.  116).  The  vein  is  dissected 
from  its  bed  for  a  distance  of  i  to  i  1/2  inches  (2.5  to  4  cm.),  and  is 
raised  from  the  wound  while  two  catgut  ligatures  are  passed  beneath 
it  by  means  of  an  aneurysm  needle,  or,  in  its  absence,  by  a  pair  of 
thumb  forceps.  The  distal  portion  of  the  vein  is  tied  off  as  low  as 
possible  with  one  ligature,  and  the  second  ligature  is  placed  high  up 
around  the  portion  of  the  vein  nearest  the  heart,  ready  to  be  tied 
(Fig.  117).     A  portion  of  the  exposed  vein  is  now  grasped  in  a  mouse- 


FiG.   116. — Intravenous  saline  infusion.      (Ashton.)     First  step,  showing  the  vein 

exposed  by  a  small  incision. 


toothed  forceps  at  a  short  distance  from  the  distal  ligature,  and, 
while  the  vein  is  put  upon  the  stretch,  a  cut  directed  obliquely  up- 
ward is  made  with  scissors  through  half  the  vein,  exposing  its  lumen 
(Fig.  118).  The  solution  is  first  allowed  to  flow  through  the  cannula 
to  expel  any  air  or  fluid  that  may  have  become  cold  by  standing,  and 
the  cannula,  with  the  solution  still  flowing,  is  then  inserted  well  into 
the  cut  vein  (Fig.  119)  and  is  secured  in  place  by  tying  the  second 
ligature.  It  is  well  to  tie  this  ligature  in  a  bow  knot  so  that  it  may 
be  easilv  loosened  when  the  cannula  is  to  be  withdrawn  at  the  end  of 


INTRAVENOUS    INFUSION 


143 


the  operation  (Fig.  120).  The  bandage  is  now  removed  from  above 
the  elbow,  and  the  saline  solution  is  allowed  to  enter  the  circulation, 
the  reservoir  being  raised  2  to  6  feet  (60  to  180  cm.)  above  the  patient. 


Fig.  117. — Intravenous  saline  infusion.  Second  step,  showing  the  distal  end 
of  the  vein  tied  and  a  second  ligature  being  passed  under  the  proximal  end  of 
the  vein 

During  the  infusion  the  temperature  of  the  solution  must  be  kept 
uniform,  the  thermometer  in  the  reservoir  being  constantly  watched, 


Fig.  118.  Fig.  119. 

Fig.  118. — Intravenous  saline  infusion.  Third  step,  showing  the  method  of 
incising  the  vein. 

Fig.  119. — Intravenous  saline  infusion.  (Ashton.)  Fourth  step,  showing  the 
cannula  being  inserted  into  the  vein. 

and  care  must  be  taken  to  replenish  the  fluid  in  the  reservoir  bejore  it 
has  all  escaped,  otherwise  air  will  enter  the  vein  when  a  fresh  supply 
is  added. 


144 


INFUSIONS    OF    PHYSIOLOGICAL    SALT    SOLUTION 


When  sufficient  solution  has  been  introduced,  the  ligature  about 
the  cannula  is  loosened,  and  the  latter  is  withdrawn.  With  this 
same  ligature  the  proximal  end  of  the  vein  may  be  then  tied  off 
(Fig.  i2i).  The  edges  of  the  skin  wound  are  united  with  several 
catgut  sutures,  and  a  sterile  gauze  dressing,  held  in  place  by  a  few 
turns  of  a  bandage,  is  applied. 

Variation  in  Technic. — Some  operators  perform  intravenous 
infusion  without  making  a  preliminary  incision  to  expose  the  vessel. 
The  same  apparatus  is  employed  as  for  an  ordinary  intravenous  infu- 


FiG.  1 20.  Fig,   121. 

Fig.  120. — Intravenous  saline  infusion.  Fifth  step,  showing  the  cannula  tied 
in  place. 

Fig.  121. — Intravenous  saline  infusion.  (Ashton.)  Sixth  step,  showing  the 
infusion  cannula  removed  and  the  proximal  end  of  the  vein  ligated. 

sion,  except  that  a  hypodermic  or  a  small  aspirating  needle  is  substi- 
tuted for  the  blunt  cannula.  The  needle,  with  the  solution  flowing, 
is  plunged  through  the  skin  directly  into  the  wall  of  the  vein. 

The  difficulty  in  placing  the  needle  accurately  in  the  vein,  espe- 
cially if  the  subject  is  very  fat,  places  a  limitation  upon  the  field 
of  usefulness  of  this  method. 


INTRAARTERIAL  INFUSION 

Saline  solution  may  be  injected  into  the  artery  instead  of  intra- 
venously, if  desired.  The  solution  may  be  injected  either  into  the 
distal  end  of  the  vessel,  or  into  the  proximal  end  against  the  blood 
current.  The  advantages  claimed  by  its  advocates  for  this  method 
of  infusion  over  the  venous  route  is  that  the  fluid,  being  first  driven 


INTRAARTERIAL   INFUSION  I45 

to  the  capillaries,  is  sent  to  the  heart  more  gradually  and  is  more 
evenly  mixed  with  the  circulating  blood  than  when  the  entire  volume 
of  solution  enters  a  vein,  and,  as  a  result,  there  is  less  disturbance 
produced  in  the  circulation.  Infusion  against  the  blood  current  has, 
in  addition,  it  is  claimed,  a  stimulating  effect  upon  the  heart. 

These  alleged  advantages  of  arterial  infusion,  however,  seem  to 
be  overbalanced  by  the  accidents  that  may  follow  employment  of 
this  method,  there  having  been  reported  a  number  of  cases  in  which 
sloughing  about  the  area  of  infusion  resulted,  in  some  even  necessi- 
tating amputation  of  the  hand,  so  that  for  ordinary  purposes  saline 
solution  introduced  through  a  vein  should  be  the  method  of  choice. 

Crile  and  DoUey  {Journal  of  Experimental  Medicine,  Dec,  1906), 
however,  have  shown  that  the  infusion  of  normal  salt  solution  and 
adrenalin  into  an  artery  against  the  blood  current  is  suspended  ani- 
mation from  the  effects  of  anesthesia  or  other  causes  is  the  most 
effective  way  of  raising  the  blood-pressure  and  stimulating  the  heart. 
They  point  out  that  adrenalin  administered  by  the  venous  system 
comes  in  contact  with  vessels  having  the  least  power  of  influencing 
blood-pressure,  and  that  before  a  material  rise  can  be  effected  by  the 
action  of  the  adrenalin  upon  the  arteries  it  is  necessary  for  the  solu- 
tion to  pass  through  the  right  heart,  the  lungs,  and  then  back  to  the 
left  heart  before  it  reaches  the  aorta  and  coronary  arteries.  This 
often  causes  an  accumulation  of  solution  and  blood  in  the  dilated 
chambers  of  the  heart,  defeating  resuscitation.  On  the  other  hand, 
by  the  arterial  route,  the  blood  and  solution  are  driven  back  toward 
the  heart  directly  affecting  the  coronary  arteries,  thus  restoring 
blood-pressure  and  stimulating  the  heart  to  beat  again.  They  have 
shown  that  it  is  possible  by  this  method  to  resuscitate  animals  that 
were  apparently  dead. 

Apparatus. — The  same  apparatus  described  on  page  139  for  intra- 
venous infusion,  or  an  infusion  cannula  attached  to  a  large  glass 
funnel  by  a  piece  fo  rubber  tubing,  may  be  employed.  In  addition, 
a  hypodermic  syringe  will  be  required. 

Site  of  Infusion. — The  carotid  artery  or  one  of  its  large  branches 
is  chosen  for  the  injection  as  being  the  most  direct  route  to  the 
coronary  arteries. 

Technic. — Crile  {Am.  Jour,  of  Med.  Sciences,  April,  1909)  gives 
the  following  technic  for  employing  arterial  infusion  in  humans  for 
purposes  of  resuscitation.  "The  patient,  in  the  prone  position,  is 
subjected  at  once  to  rapid  rhythmic  pressure  upon  the  chest,  with 
one  hand  on  each  side  of  the  sternum.     This  pressure  produces 


146 


INFUSIONS    OF   PHYSIOLOGICAL    SALT   SOLUTION 


artificial  respiration  and  a  moderate  artificial  circulation.  A  can- 
nula is  inserted  toward  the  heart  into  an  artery.  Normal  saline, 
Ringer's  or  Locke's  solution,  or,  in  their  absence,  sterile  water,  or,  in 
extremity,  even  tap  water  is  infused  by  means  of  a  funnel  and  rubber 
tubing.  But  as  soon  as  the  flow  has  begun  the  rubber  tubing  near 
the  cannula  is  pierced  with  a  hypodermic  syringe  loaded  with  i  to 
1000  adrenalin  chlorid  and  15  to  3oTn,  (i  to  2  c.c.)  are  at  once  in- 
jected. Repeat  the  injection  in  a  minute,  if  needed.  Synchro- 
nously with  the  injection  of  the  adrenalin,  the  rhythmic  pressure  on 
the  thorax  is  brought  to  a  maximum.  The  resulting  artificial  cir- 
culation distributes  the  adrenalin  that  spreads  its  stimulating  contact 


Fig.   122. — ^Showing  the  method  of  infusing  salt  and  adrenalin  solution  into  the 
carotid  artery.      (After  Da  Costa.) 

with  the  arteries,  bringing  a  wave  of  powerful  contraction  and  pro- 
ducing a  rising  arterial,  hence  coronary,  pressure.  When  the  coro- 
nary pressure  rises  to,  say,  40  mm.  or  more,  the  heart  is  liable  to 
spring  into  action.  The  first  result  of  such  action  is  to  spread  still 
further  the  blood-pressure-raising  adrenalin,  causing  a  further  and 
vigorous  rise  in  blood-pressure,  possibly  even  doubling  the  normal." 
.  .  .  "Just  as  soon  as  the  heart-beat  is  established,  the  cannula 
should  be  withdrawn,  first,  because  it  is  no  longer  needed,  and,  second 
the  rising  blood-pressure  will  drive  a  current  of  blood  into  the  tube 
and  funnel." 

Dawbarn's  Emergency  Method  of  Intraarterial  Infusion. — 
This  consists  in  injecting  saline  solution  into  the  circulation  through  a 


INTRAARTERIAL   INFUSION 


147 


hypodermic,  or  a  long  line  aspirating  needle,  inserted  into  the  com- 
mon femoral  artery.  Dawbarn  recommends  it  as  an  emergency 
method  in  the  absence  of  cannula  and  instruments  necessary  for  in- 


PiG.   123. — Apparatus  for  infusing  salt  solution  into  an  artery  in    Dawbarn's 

emergency  method. 

travenous  infusion,  or  where  the  superficial  veins  are  small  and  very 
difficult  to  locate. 

Apparatus. — A  hypodermic  needle,  or  a  long  fine  aspirating 
needle,  and  an  ordinary  Davidson  syringe  (Fig.  123)  are  all  that  are 
required. 


Fig.   124. — Showing  the  method  of  infusing  salt  solution  into  the  femoral  artery. 

Technic. — The  femoral  artery  is  first  carefully  defined  just 
below  Poupart's  ligament.  The  aspirating  needle  is  then  forced  by 
a  slow  rotary  movement  directly  into  the  artery,  entering  it  at  right 
angles.     As  soon  as  the  needle  enters  the  vessel,  bright  red  blood 


148 


INFUSIONS    OF   PHYSIOLOGICAL   SALT   SOLUTION 


will  fill  its  lumen.  The  rubber  tubing  of  the  syringe,  which  has  been 
previously  filled  with  saline  fluid,  is  then  slipped  over  the  base  of  the 
needle  and  is  firmly  secured  in  place  by  tying.  The  fluid  is  then 
steadily  pumped  from  a  basin  directly  into  the  arterial  circulation 
(Fig.  124).  According  to  Dawbarn,  it  requires  about  half  an  hour  to 
inject  a  pint  (500  c.c.)  of  solution  by  this  method.  If  a  fountain 
syringe  is  used  instead  of  a  Davidson  syringe,  it  must  be  held  at 
least  6  feet  (180  cm.)  above  the  patient  to  secure  the  necessary 
pressure,  otherwise  the  blood  will  be  forced  back  up  the  tube. 

HYPODERMOCLYSIS 

The  subcutaneous  method  of  infusion  does  not  permit  as  rapid 
an  introduction  of  large  quantities  of  solution  as  the  intravenous, 


Fig.   125. — Apparatus  for  giving  hypodermoclysis.     (Ashton.) 


on  account  of  the  slowness  with  which  the  solution  is  absorbed.  It 
is  indicated  in  the  same  conditions  as  venous  infusions,  when  urgency 
is  not  of  prime  importance.  It  is  also  frequently  used  as  an  adjunct 
to  intravenous  infusion.  Hypodermoclysis  is  contraindicated  where 
the  tissues  are  edematous  from  dropsy,  or  where  the  circulation  is 
so  feeble  that  absorption  of  the  solution  is  very  slow  or  impossible. 
Apparatus. — There  will  be  required  a  thermometer,  a  graduated 
glass,  irrigating  jar,  6  feet  (180  cm.)  of  rubber  tubing,  1/4  inch  (6 
mm.)  in  diameter,  and  an  aspirating  needle  of  fair  size  (Fig.  125). 
When  it  is  desired  to  introduce  the  fluid  under  both  breasts  at  once, 


HYPODERMOCLYSIS  I49 

two  needles  fastened  to  the  rubber  tubing  by  means  of  a  Y-shaped 
glass  connection,  as  shown  in  Fig.  126,  may  be  employed. 

In  an  emergency,  a  glass  funnel  or  a  fountain  syringe,  to  which  is 
attached  an  ordinary  hypodermic  needle  by  several  feet  of  rubber 
tubing,  may  be  utilized. 

Asepsis. — The  necessary  apparatus  should  be  boiled,  the  seat  of 
injection  painted  with  tincture  of  iodin,  and  the  operator's  hands 
carefully  cleansed.  The  thermometer  is  sterilized  by  immersion  in 
a  I  to  500  bichlorid  solution  for  ten  minutes,  followed  by  rinsing  in 
sterile  water. 

Temperature  of  the  Solution. — The  solution  should  enter  the  body 
at  about  110°  F.  (43°  C).  When  using  a  large  aspirating  needle  the 
fluid  in  the  reservoir  should  be  kept  at  a  constant  temperature  of 
about  3  degrees  higher.  If  a  h^'podermic  needle  be  employed,  about 
5  degrees  should  be  allowed  for  cooling. 

Rapidity  of  Flow. — As  the  fluid  is  taken  up  with  comparative 
slowness  from  the  subcutaneous  tissues,  the  injection  is  given  less 
rapidly  than  by  the  intravenous  method.     With  a  fair-sized  needle 


Fig.   126. — Showing  two  needles  arranged  for  hypodermoclysis. 

about  a  pint  (500  c.c.)  of  fluid  may  be  injected  in  from  twenty  to 
thirty  minutes,  the  reservoir  being  held  from  3  to  4  feet  (90  to  120 
cm.)  above  the  patient.  W^hen  a  hypodermic  needle  is  employed, 
the  needle  being  so  small  in  caHber,  it  will  be  necessary  to  raise  the 
reservoir  5  or  6  feet  (150  to  180  cm.)  to  get  sufiicient  force. 

Quantity  Given. — Injections  of  small  quantities  of  solution,  re- 
peated several  times,  give  better  results  than  a  single  large  injection. 
As  a  rule,  from  8  to  16  ounces  (250  to  500  c.c.)  of  solution  are  intro- 
duced at  a  single  injection,  and  repeated  in  a  few  hours,  if  necessary. 
According  to  Hildebrand,  it  is  not  safe  to  introduce  a  larger  quantity 
of  solution  in  fifteen  minutes  than  i  dram  (4  c.c.)  to  each  pound 
(453  gm.)  of  body  weight.  If  this  ratio  is  exceeded,  the  fluid  accu- 
mulates and  the  tissues  become  water-logged,  as  the  kidneys  do  not 
secrete  rapidly  enough  to  carry  it  off.  Furthermore,  very  large 
quantities  of  solution  should  not  be  injected  into  one  area,  as  it  may 


ISO 


INFUSIONS    OF    PHYSIOLOGICAL    SALT    SOLUTION 


produce  undue  distention  of  the  tissues  and  consequent  sloughing 
from  the  prolonged  anemia. 

Sites  of  Injection. — The  area  chosen  for  the  injection  should  be 
in  a  region  free  from  large  blood-vessels  and  nerves  and  where  there 


Fig.   127. — Sites  for  hypodermoclysis. 

is  an  abundance  of  loose  connective  tissue.  The  usual  sites  are: 
(i)  under  the  mammary  glands;  (2)  in  the  subcutaneous  tissue  be- 
tween the  crest  of  the  ilium  and  the  last  rib;  (3)  in  the  subcutaneous 
tissue  in  the  axillary  space;  (4)  in  the  subcutaneous  tissue  on  the  inner 
surfaces  of  the  thighs  (Fig.  127). 


Fig.   128. — Giving  hypodermoclysis  under  the  left  breast.      (Ashton.) 

Anesthesia. — The  point  of  skin  puncture  may  be  anesthetized  by 
the  injection  of  a  drop  or  tw^o  of  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain,  or  by  freezing  with  ethyl  chlorid 
or  salt  and  ice. 


HYPODERMOCLYSIS  I51 

Technic. — The  reservoir  is  raised  from  3  to  4  feet  (90  to  120  cm.) 
above  the  patient,  and  some  of  the  fluid  is  allowed  to  escape  from  the 
needle,  to  expel  any  air  or  cold  solution.  With  the  solution  still 
flowing,  the  operator,  using  steady  pressure,  inserts  the  needle  ob- 
liquely well  into  the  subcutaneous  tissue.  As  the  solution  enters,  a 
swelling  appears  in  the  subcutaneous  tissues  which,  however,  slowly 
subsides  as  the  fluid  is  absorbed  (Fig.  128).  If,  as  soon  as  the  tissues 
in  one  area  become  distended,  the  needle  be  partly  withdrawn  and 
its  direction  be  changed  shghtly,  a  large  amount  of  solution  may  be 
infiltrated  over  a  wide  area  without  producing  too  great  tension  at 
any  one  spot.  The  absorption  of  the  solution  may  be  hastened  by 
gentle  massage  over  the  infiltrated  area.  During  the  operation,  the 
temperature  of  the  solution  is  to  be  kept  uniform,  and  sufficient 
solution  must  be  in  the  reservoir  at  all  times  to  prevent  air  from 
entering  the  tube. 

When  the  desired  quantity  of  solution  has  been  introduced,  the 
needle  is  withdrawn  and  the  finger  is  placed  over  the  puncture  to  pre- 
vent the  escape  of  fluid.  The  puncture  is  then  sealed  with  sterile 
cotton  and  collodion. 

RECTAL  INFUSION.     (See  page  554.) 


CHAPTER  VI 

ACUPUNCTURE,     VENESECTION,     SCARIFICATION,     SUBCU- 
TANEOUS DRAINAGE  FOR  EDEMA,  CUPPING,  AND  LEECHING 

ACUPUNCTURE 

This  is  a  small  operation  which  consists  in  the  insertion  of  needles 
or  other  small  sharp  instruments  either  into  the  superficial  tissues  for 
the  purpose  of  relieving  the  tension  in  swollen  or  edematous  areas,  or 
directly  into  muscles  or  nerves  for  the  relief  of  the  pain  of  muscular 
rheumatism  or  of  neuritis. 

For  the  relief  of  tension,  and  to  furnish  an  exit  for  the  effusion 
beneath  the  skin,  acupuncture  is  frequently  employed  in  edema 
involving  the  extremities,  labia,  or  scrotum,  though,  if  the  tissues  are 
so  greatly  distended  that  sloughing  seems  imminent,  incisions  should 
be  substituted  for  the  punctures.  In  acute  epididymitis  and  similar 
cases  acupuncture  is  also  often  used  with  good  results. 

Of  the  second  class  of  cases  it  is  employed  with  greatest  success 
in  lumbago  and  sciatica.  Just  how  acupuncture  acts  in  such  cases  is 
not  clear;  relief  of  pain  is  not  invariably  afforded,  for  in  some  cases  it 
seems  to  have  no  effect,  but  at  any  rate  the  method  is  worthy  of 
trial,  especially  before  more  severe  forms  of  treatment,  as  nerve 
stretching,  etc.,  are  instituted. 

Instruments. — To  relieve  tension,  the  pun,ctures  may  be  made 
with  triangular-pointed  surgeon's  needles  or  with  a  very  narrow- 


FiG.   129. — Instruments  for  acupuncture. 

bladed  bistoury  (Fig.  129).  Employed  for  the  relief  of  the  pain  of 
muscular  rheumatism  or  neuritis,  half  a  dozen  cyhndrical  needles 
about  3  or  4  inches  (7.5  to  10  cm.)  long  will  be  required.  Long  darn- 
ing needles  or  sharp  hat  pins  will  answer  very  well. 

Asepsis. — The  skin  should  be  sterilized  by  painting  the  sites  of 
puncture  with  tincture  of  iodin;  the  instruments  are  to  be  boiled; 
and  the  operator's  hands  are  cleansed  as  for  any  operation.  It  is 
especially  important  to  observe  all  aseptic  precautions  both  during 
and  after  puncture  of  dropsical  effusions,  as  the  tissues  in  such  cases 
have  poor  resistance  and  are  a  good  soil  for  infection. 

1^2 


ACUPUNCTURE  I 53 

Anesthesia. — There  is  but  little  pain  connected  with  this  opera- 
tion, but  if  desired  the  skin  at  the  sites  of  puncture  may  be  frozen  with 
ethyl  chlorid. 

Technic. — Puncture  for  the  relief  of  tension  simply  consists  in 
making  a  single  or,  when  required,  numerous  deep  stabs  with  the 
needle  or  bistoury  into  the  swollen  area,  avoiding  injury  to  important 
vessels  or  nerves.  This  allows  the  escape  of  serum  which  may  be 
encouraged  by  the  application  of  moist  heat  in  the  form  of  dressings 
saturated  with  some  mild  antiseptic,  as  boric  acid. 

When  treating  muscular  rheumatism  by  this  method,  several 
sharp  round  needles  are  thrust  through  the  skin  into  the  painful  parts 
of  the  affected  muscle  to  a  depth  of  i  to  i  1/2  inches  (2.5  to  4  cm.), 
or  more,  depending  on  the  amount  of  adipose  tissue,  and  are  allowed 
to  remain  in  place  five  to  ten  minutes.  In  removing  them,  care  must 
be  taken  not  to  break  them  off  in  the  tissues.  Not  infrequently  the 
relief  of  pain  is  immediate. 

Applied  to  a  nerve,  the  same  technic  is  employed.  An  endeavor 
is  made  to  transfix  the  affected  nerve  with  from  four  to  six  needles 
along  the  painful  part  of  its  course.  It  may  sometimes  be  difficult 
to  strike  some  of  the  smaller  nerves,  but  with  a  large  nerve  like  the 
sciatic  there  is  usually  no  trouble.  The  patient's  sensations  will  be  a 
guide  as  to  whether  the  nerve  is  reached,  for,  as  soon  as  this  occurs, 
a  sharp  pain  will  be  felt  different  from  that  experienced  as  the  needle 
passes  through  the  superficial  tissues.  The  needles  when  properly 
placed  should  be  left  in  site  about  five  or  ten  minutes. 

VENESECTION 

The  operation  of  venesection,  or  phlebotomy,  consists  in  the  open- 
ing of  some  superficial  vein  and  the  abstraction  of  blood  from  the 
general  circulation  for  therapeutic  purposes. 

The  beneficial  effects  of  bleeding  have  been  recognized  from  the 
time  of  Hippocrates.  Unfortunately,  though,  bleeding  was  formerly 
much  overdone,  and  in  the  early  part  of  the  last  century  it  came  to  be 
the  custom  to  bleed  indiscriminately  for  almost  any  sickness.  In 
consequence  of  its  abuse  this  valuable  operation  has  lost  much  of  its 
popularity  and  is  now  but  rarely  practised.  Popular  prejudice, 
furthermore,  often  prevents  its  employment,  so  that  even  in  cases 
where  it  is  of  undoubted  therapeutic  value  the  practitioner  of  to-day 
prefers  to  put  his  trust  in  drugs  to  accomplish  the  desired  effects. 
In  spite  of  this  neglect,  bleeding  is  a  powerful  and  beneficial  thera- 
peutic measure  when  employed  in  the  proper  class  of  cases,  and,  as 


154 


ACUPUNCTURE,   VENESECTION,    SCARIFICATION,    ETC. 


Hare  points  out,  "  the  indications  for  venesection  are  as  clear  and  well 
defined  as  are  the  indications  for  any  remedy." 

Indications. — These  may  be  better  appreciated  by  an  understand- 
ing of  what  venesection  accomplishes.  In  the  first  place,  through 
the  mechanical  effect  upon  the  circulation  of  removal  of  a  quantity 
of  blood,  the  tension  in  the  blood-vessels  is  diminished,  and  the  vas- 
cular tone  becomes  more  evenly  balanced,  so  that  an  engorged  area, 
where  the  vessels  are  relaxed  and  dilated,  is  relieved.  At  the  same 
time  the  speed  of  the  circulating  blood  in  the  capillaries  is  accelerated, 
and  stasis  is  further  prevented,  and  the  absorption  of  exudates 
hastened. 

Upon  the  general  system  venesection  also  has  beneficial  effects 
causing  a  lessened  activity  of  the  various  functions;  the  cardiac  and 


Fig.    130. — Instruments    for    venesection,      i,  Glass   graduate;  2,    ethyl    chlorid; 
3,  scalpel;  4,  stick  for  patient  to  grasp;  5,  bandages. 

respiratory  actions  become  less  active,  the  temperature  is  lowered, 
and  cell  proliferation  is  diminished. 

In  general,  then,  it  may  be  said  that  venesection  is  indicated  for 
the  relief  of  congestion  in  cases  of  excessive  vascular  tension  evidenced 
by  a  rapid,  strong,  full,  incompressible  pulse,  while  low  arterial  ten- 
sion and  circulatory  depression  with  a  slow,  soft,  irregular,  and  com- 
pressible pulse  are,  as  a  rule,  contraindications.  Thus  in  sthenic 
t)^es  of  croupous  pneumonia  with  dilated  right  heart,  dyspnea,  and 
cyanosis,  in  pleurisy,  peritonitis,  pulmonary  edema,  pulmonary 
hemorrhage,  emphysema  with  marked  dyspnea  and  cyanosis,  conges- 
tion of  the  brain,  cardiac  valvular  disease  with  engorged  right  heart, 
bleeding  both  lowers  vascular  tension  and  relieves  engorgement.  In 
cases  where  toxins  or  other  deleterious  substances  are  present  in  the 


VENESECTION 


■:>:) 


blood,  as  in  eclampsia,  uremic  convulsions,  illuminating-gas  poison- 
ing, poisoning  by  hydrogen  sulphid,  prussic  acid,  etc.,  bleeding  serves 
the  double  purpose  of  reducing  arterial  tension  and  removing  a  defi- 
nite quantity  of  toxic  material.  Large  quantities  of  blood  may  be 
abstracted  in  such  cases,  followed  by  transfusion  or  saline  infusion 
(the  so-called  "blood  washing")  with  unquestionably  good  results. 

Instruments. — There  will  be  required  a 
scalpel  or  bistoury,  a  sterile  gauze  pad, 
several  bandages,  a  round  object  as  a  stick 
or  roller  bandage  for  the  patient  to  grasp, 
and  a  large  glass  graduate  (Fig.  130). 

Quantity  Withdrawn. — On  an  average 
from  6  ounces  (180  c.c.)  to  15  ounces  (450 
c.c.)  may  be  abstracted  from  an  adult,  and 
from  I  ounce  (30  c.c.)  to  3  ounces  (90  c.c.) 
from  a  child,  depending  on  the  condition 
and  the  character  of  the  pulse  and  upon  the 
appearance  of  the  patient.  This  amount 
may  be  increased,  hov/ever.  if  the  venesection 
is  to  be  supplemented  by  transfusion  or 
saline  infusion.  Under  such  conditions  20 
ounces  (600  c.c.)  or  more  may  be  removed 
from  an  adult. 

Site  of  Operation. — Some  one  of  the 
large  veins  in  front  of  the  elbow-joint  is 
usually  selected  (Fig.  131).  but  the  internal 
jugular  or  internal  saphenous  may  be 
utilized. 

Position  of  the  Patient. — The  patient  should  be  sitting  upright  or 
in  a  semirecHning  position  on  a  couch,  with  his  head  turned  away 
from  the  seat  of  operation,  as  the  sight  of  blood  may  cause  faintness. 
The  semiupright  position  is  a  safeguard  against  withdrawing  too 
much  blood,  as  the  patient  becomes  faint  sooner  than  if  he  were  lying 
down. 

Asepsis. — While  this  is  a  small  operation,  at  the  same  time  all 
aseptic  precautions  should  be  observed.  In  former  times  many 
patients  lost  their  lives  from  septic  thrombosis.  Accordingly,  the 
instruments  and  dressings  should  be  sterile,  and  the  hands  of  the 
operator  should  be  as  carefully  prepared  as  for  any  operation.  The 
bend  of  the  patient's  elbow  is  first  shaved  if  necessary  and  is  then 
painted  with  tincture  of  iodin. 


Fig.  131. — Superficial 
veins  of  the  forearm. 
(Ashton.) 


156 


ACUPUNCTURE,   VENESECTION,    SCARIFICATION,    ETC. 


Anesthesia. — The  area  of  incision  may  be  anesthetized  by  infil- 
trating with  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain  or  a  i 
per  cent,  novocain  solution,  or  by  freezing  with  ethyl  chlorid  or  salt 
and  ice. 

Technic. — A  few  turns  of  a  roller  bandage  are  placed  about  the 
patient's  arm  above  the  elbow  with  just  sufficient  tension  to  obstruct 
the  venous  circulation  and  make  the  veins  stand  out  prominently 
(Fig.  132).  By  directing  the  patient  to  grasp  some  object  and  work 
his  fingers  while  the  arm  is  hanging  down,  the  veins  will  become  even 
more  distended.  The  patient's  arm  is  then  placed  in  an  extended  and 
abducted  position.     The  operator  next  identifies  either  the  median 


Fig.   132. — Venesection.      First  step,  showing  the  application  of  the  bandage  to 

the  arm.      (Ashton.) 

basilic  or  median  cephalic  vein,  and,  compressing  it  with  his  left 
thumb  placed  just  below  the  seat  of  incision,  makes  a  small  cut  trans- 
versely to  the  long  axis  of  the  vein  (Fig.  133),  which  is  exposed  by 
dissection  and  a  small  opening  made  in  its  anterior  wall  (Fig.  134). 
The  arm  is  then  turned  over,  the  thumb  removed,  and  the  blood  is 
permitted  to  escape  into  a  glass  graduate  (Fig.  135). 

While  cutting  down  on  the  vein  care  must  be  taken  not  to  disturb 
the  relative  positions  of  the  skin  and  vein  by  drawing  on  the  skin, 
otherwise  the  cut  through  the  skin  and  that  into  the  vein  will  not 
coincide  when  the  finger  is  removed  and  the  skin  released,  with  the 


VENESECTION 


157 


result  that  the  blood  will  escape  under  the  skin  into  the  subcutaneous 
tissues.     If  the  median  basilic  vein  is  utilized,  the  incision  into  its 


Fig.  133.  Fig.   134. 

Fig.   133. — Venesection.     Second    step,   vein   exposed   and    operator's    finger 
compressing  the  distal  portion  of  the  vessel. 

Fig.  134. — Venesection.     Third  step,  showing  incision  into  vein  walls. 


Fig.   135. — Venesection.     Fourth  step,  showing  the  operator's  finger  removed  from 
the  vein  and  the  blood  being  collected  in  a  glass  graduate. 


wall  must  not  be  made  too  deeply  for  fear  of  wounding  the  brachial 
artery. 


158  ACUPUNCTURE,   VENESECTION,    SCARIFICATION,    ETC. 

When  a  sufficient  quantity  of  blood  has  been  abstracted,  a  gauze 
pad  is  held  over  the  wound  by  the  thumb,  and  the  bandage  is  removed 
from  the  arm.  The  incision  is  then  dressed  with  a  sterile  gauze 
compress  held  in  place  by  a  bandage.  If  simple  compression  is  not 
sufficient  to  stop  the  breeding,  both  ends  of  the  vein  should  be  sought 
and  ligated  with  fine  catgut.  The  patient  should  be  instructed  to 
carry  the  arm  in  a  sling  for  a  few  days  following  this  operation. 

Complications. — The  most  serious  complication  is  a  puncture  of 
the  brachial  artery  by  the  incision  into  the  vein  producing  an  arterio- 
venous aneurysm.  This  may  be  avoided  by  carefully  cutting  down 
upon  the  vein  and  not  incising  skin,  superficial  tissues,  and  vein  at 
one  cut. 

Sometimes  a  very  painful  neuralgia  is  a  sequel  to  the  operation, 
probably  due  to  injury  to  some  of  the  cutaneous  nerves  of  the  region. 
If  the  instruments  are  clean  and  proper  aseptic  precautions  are 
observed,  septic  thrombosis  is  not  to  be  feared. 

Variations  in  Technic. — Some  operators  extract  the  blood  by 
means  of  a  medium  sized  aspirating  needle  attached  to  a  large 
antitoxin  syringe  or  through  a  vein  trocar  to  which  is  attached  a  piece 
of  rubber  tubing  which  leads  to  a  glass  graduate.  The  needle  or  tro- 
car is  plunged  through  the  skin  into  the  vein  in  the  same  manner  as 
is  done  in  withdrawing  blood  for  bacteriological  examination  (see 
page  223). 

SCARIFICATION     ' 

Scarification  consists  in  making  multiple  incisions  into  the  tissues 
for  the  relief  of  local  congestion  or  tension.  By  this  method  of  local 
bleeding,  engorged  blood-vessels  are  emptied  and  effusions  of  serum 
are  permitted  to  escape;  thus  undue  tension  from  exudates  is  relieved, 
and  the  tendency  of  the  tissues  to  slough  is  lessened. 

For  the  relief  of  inflammatory  conditions  of  the  skin  and  mucous 
membranes  scarification  finds  its  chief  apphcation.  Thus  in  inflamed 
ulcers,  threatened  gangrene  from  extreme  tension,  phlegmonous  ery- 
sipelas, etc.,  prompt  relief  often  follows  its  use.  Scarification  may 
also  be  employed  in  the  place  of  multiple  punctures  for  the  rehef  of 
tension  in  marked  edema  of  the  extremities,  labia,  and  scrotum. 
In  urinary  infiltration  deep  scarification  becomes  necessary  to  allow 
the  escape  of  the  extravasation  and  to  prevent  sloughing.  In  inflam- 
matory aff"ections  and  edemas  of  the  pharynx,  uvula,  tonsils,  and  glot- 
tis it  is  often  indicated;  in  involvement  of  the  latter  with  progressive 


SCARIFICATION 


159 


dyspnea  and  cyanosis  the  scarification  should  be  performed  without 
any  delay. 

Instruments. — An  ordinary  scalpel  or  bistoury  is  all  that  is  neces- 


FiG.    136. — Automatic  scarificator. 

sary.  A  special  scarifier  (Fig.  136)  may  be  employed,  however,  if 
desired.  This  instrument  consists  of  a  metal  box  containing  a  num- 
ber of  sharp  blades,  which,  upon  touching  a  spring,  are  suddenly 


Fig.    137. — Knife  wrapped  with  adhesive  plaster. 

forced  out  in  such  a  way  as  to  cut  the  tissues  to  which  the  instrument 
is  applied  to  any  desired  depth. 

For  incising   the   tonsil,    glottis,    etc.,    a   sharp-pointed   curved, 
bistoury  wrapped  with  adhesive  plaster  to  within  1/4  inch  (6  mm.)  of 


Fig.    138. — Protected  laryngeal  knife. 

its  point  (Fig.  137)  should  be  employed  in  the  absence  of  a  protected 
laryngeal  knife  (Fig.  138). 

Asepsis. — The  operation  must  be  performed  with  all  the  usual 
aseptic  precautions. 


i6o 


ACUPUNCTURE,    VENESECTION,    SCARIFICATION,    ETC. 


Anesthesia. — Where  extensive  incisions  are  required,  as  in  urinary 
extravasation,  for  example,  nitrous  oxid  anesthesia  will  be  required. 
In  other  cases  local  anesthesia  with  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  novocain  solution,  or  by  freezing,  if  the  nutrition  of 
the  parts  is  unimpaired,  will  suffice.  Mucous  surfaces  may  be  anes- 
thetized with  a  4  per  cent,  solution  of  cocain  sprayed  upon  or  applied 
directly  to  the  parts. 

Technic. — The  incisions  are  made  in  parallel  rows  over  the 
inflamed  area,  and,  according  to  the  indications,  they  may  or  may  not 
extend  through  the  entire  thickness  of  the  skin.  They  should  always 
be  made  in  the  long  axis  of  a  limb  (Fig.  139)  and  in  other  regions  paral- 
lel to  the  lines  of  cleavage,  care  being  taken  not  to  wound  the  super- 
ficial nerves  or  large  veins.  Warm  fomentations  applied  to  the  scar- 
ified area  assist  in  maintaining  the  escape  of  blood  and  serum. 


Fig.   139. — Showing  the  method  of  scarifying  a  Hmb. 

Scarification  of  the  larynx  is  performed  with  the  aid  of  laryngos- 
copy (page  389).  When  a  clear  view  of  the  edematous  parts  has 
been  obtained,  incisions  about  1/4  inch  (6  mm.)  in  length  are 
made  with  the  point  of  the  protected  bistoury  in  the  areas  of  most 
marked  swelling.  When  it  is  feasible,  these  incisions  are  made  on  the 
outer  surfaces  of  the  parts  to  avoid  having  blood  flow  into  the  larynx. 
A  gargle  of  hot  water  or  an  inhalation  of  steam  is  then  employed  to 
encourage  the  bleeding  and  escape  of  the  serum.  This  often  gives 
complete  relief  in  a  few  hours;  if  the  symptoms  are  not  improved, 
however,  or  the  dyspnea  recurs,  tracheotomy  (page  424)  must  be 
performed  without  hesitation. 

DRAINAGE  IN  EDEMA  OF  THE  LOWER  EXTREMITIES 

Three  operative  procedures  may  be  employed  for  reKeving  edema 
of  the  lower  extremities  when  the  tension  becomes  too  great,  namely. 


DRAINAGE    IN   EDEMA    OF    THE    LOWER    EXTREMITIES 


l6l 


multiple  punctures  (page  152),  incision  (page  158),  and  drainage  by 
the  trocar  and  cannula.  Of  these,  the  latter  is  less  troublesome,  more 
cleanly,  and  certainly  far  more  comfortable  for  the  patient. 

From  one  to  four  cannulas  may  be  employed  at  a  time,  and  con- 
siderable fluid  may  be  drained  off  in  this  way.  When  more  than  one 
cannula  is  used  several  quarts  may  be  abstracted  in  twenty-four 
hours,  but  the  operator  should  be  cautious  about  withdrawing  too 
great  a  quantity  for  fear  of  inducing  a  condition  of  cerebral  anemia. 
Should  such  a  condition  be  produced,  the  drainage  should,  of  course, 
be  immediately  stopped  and  stimulants  administered. 


Fig.  140. — Southey's  trocars  and  cannula. 


Apparatus. — Southey's  tubes  (Fig.  140)  or  those  of  Curschmann 
may  be  employed.  The  former  are  made  in  a  set  consisting  of  one 
trocar  and  four  cannulae.  Each  cannula  has  lateral  openings  as  well 
as  a  distal  opening.  The  lumen  of  the  cannula  is  about  1/25  inch 
(i  mm.)  in  diameter.  In  addition,  pieces  of  rubber  tubing  about 3  feet 
(90  cm.)  long  to  lead  from  the  tubes  to  receptacles  are  required. 

Sites  of  Puncture. — The  back  or  outer  sides  of  the  legs  are  usually 
chosen. 

Asepsis. — Rigid  asepsis  should  be  observed  to  avoid  infection. 
The  trocar  and  cannula  are  boiled,  the  operator's  hands  carefully 
cleansed,  and  the  spot  chosen  for  puncture  is  first  shaved  and  then 
painted  with  tincture  of  iodin. 


l62 


ACUPUNXTURE,   VEXESECTIOX,    SCARIFICATION,    ETC. 


Technic. — One  cannula  at  a  time  is  placed  on  the  trocar  and  is 
inserted  an  inch  (2.5  cm.)  or  more  into  the  subcutaneous  tissues  at 
right  angles  to  the  surface.  The  trocar  is  then  removed  and  to  the 
free  end  of  the  cannula  is  attached  a  rubber  tube  idled  with  some 
antiseptic  solution.  The  distal  end  of  the  tube  is  allowed  to  drain  into 
a  basin  placed  upon  the  floor  by  the  side  of  the  patient's  bed  (Fig. 
141).  Three  or  more  cannulae  are  introduced  in  this  manner.  The 
cannulse  should  be  secured  in  place  by  means  of  adhesive  plaster,  and 
sterilized  dressings  should  be  placed  about  them.     Elevation  of  the 


Fig.   141. — Showing  the  method  of  draining  an  edematous  limb  with  Southey's 
cannula.      (After  Gumprecht.) 

head  of  the  bed  from  6  to  24  inches  (15  to  60  cm.)  allows  the  fluid  to 
gravitate  to  the  extremities  and  is  of  considerable  help  when  the 
edema  is  generalized.  Care  should  be  taken  that  the  cannula?  are  not 
displaced,  and  for  this  reason,  with  restless  patients,  it  is  better  to 
remove  them  at  night.  It  is  preferable  in  any  case  to  make  new 
punctures  than  to  leave  the  cannulae  in  place  for  several  days.  After 
removal  of  the  cannulae,  the  sites  of  the  punctures  should  be  sealed 
with  collodion  and  cotton. 

CUPPING 

Cupping  may  be  either  dry  or  wet  according  to  the  method  of 
application.  Dry  cupping  produces  a  local  congestion  of  the  super- 
ficial tissues  and  relieves  congestion  of  the  deeper  .subjacent  organs 


CUPPING 


103 


by  deviating  the  blood  from  these  parts.  Wet  cupping,  in  addition, 
actually  abstracts  blood  from  the  tissues.  Cupping  finds  its  chief 
appKcation  in  the  relief  of  congestion  of  deeply  placed  organs  as  the 
brain,  spinal  cord,  lungs,  liver,  kidneys,  etc. 

Apparatus. — Special  cupping  glasses  supplied  with  a  rubber  bulb 
for  exhausting  the  air  (Fig.  142)  are  obtainable  and  will  be  found  very 


Fig.   142. — Bulb  form  of  cupping  glass. 

convenient,  but  the  ordinary  cupping  glasses  in  which  the  vacuum  is 
created  by  igniting  a  httle  alcohol  smeared  over  the  interior  of  the  cup 
are  just  as  efficient.  In  an  emergency,  2-ounce  (60  c.c.)  whisky  or 
wineglasses,  or  thick  tumblers  with  smooth  rounded  edges  will  answer 


Fig.   143. — Instruments  for  wet  cupping,      i,  Cupping  glasses;  2,  swab  in  alcohol; 
3,  alcohol  lamp;  4,  scalpel. 


equally  well.  From  8  to  1 2  cups  will  be  required  in  dry  cupping  and 
from  2  to  6  in  wet  cupping,  depending  upon  the  extent  of  surface  to 
which  they  are  to  be  applied. 

In  addition  to  the  cups  there  should  be  provided  some  alcohol,  a 
small  stick  to  the  end  of  which  a  cotton  swab  is  attached,  and  matches 


164 


ACUPUNCTURE,  VENESECTION,    SCARIFICATION,    ETC. 


or  an  alcohol  flame.     If  wet  cupping  is  to  be  employed,  there  will 
also  be  required  a  sharp  scalpel  or  lancet  (Fig.  143). 

Sites  of  Application. — Cupping  glasses  are  never  to  be  applied 
directly  over  inflamed  tissues  on  account  of  the  pain  that  would 
result.     Nor  should  they  be  placed  over  bon}'  or  irregular  surfaces  on 


Fig.   144. — Cupping.     First  step,  swabbing  the  interior  of  the  cupping  glass  with 

alcohol. 

account  of  the  impossibility  of  excluding  air.  Where  the  brain  is  the 
seat  of  the  trouble,  the  cups  are  applied  to  the  back  of  the  neck;  in 
pericarditis,  to  the  precordial  region;  in  involvement  of  the  lungs  or 
pleura,  to  the  chest  between  the  vertebral  column  and  scapular  line; 


Fig.   145. — Cupping.     Second  step,  igniting  the  alcohol  in  the  cupping  glass. 

in  renal  congestion  or  acute  nephritis,  to  the  lumbar  regions;  in  affec- 
tions of  the  eye,  to  the  temples;  etc.  Wet  cups,  however,  are  often 
followed  by  scarring,  hence  they  should  not  be  applied  over  conspicu- 
ous regions  or  upon  the  shoulders  or  chests  of  women. 


CUPPING 


165 


Technic. — i.  Dry  Cupping. — Any  hair  should  be  first  shaved  off 
the  part  and  the  surface  of  the  skin  dampened  with  warm  water  so 
that  the  cups  will  adhere.  To  apply  caps  supplied  with  an  exhausting 
bulb,  simply  compress  the  rubber  bulb,  then  place  the  cup  upon  the 
skin,  and  release  the  bulb.  A  partial  vacuum  is  thus  produced  and 
the  skin  and  underlying  tissues  engorged  with  blood  are  sucked  up 
into  the  cup. 

When  ordinary  cups  are  employed,  the  swab,  saturated  with 
alcohol,  is  lightly  wiped  over  the  interior  of  each  cup  (Fig.  144), 
care  being  taken  not  to  leave  any  excess  of  alcohol  that  may  run  down 


Fig. 


Cupping.     Third  step,  the  application  of  the  cups. 


over  the  edges.  The  alcohol  is  then  ignited  (Fig.  145),  and  the  cup  is 
quickly  and  tightly  applied  to  the  skin.  The  contained  air  is  rapidly 
exhausted  by  the  flame,  and,  as  the  cup  cools,  a  strong  vacuum  is 
created,  which  draws  up  the  underlying  tissues  (Fig.  146))  and  pro- 
duces local  congestion.  A  number  of  cups — anywhere  from  eight  to 
ten — may  be  applied  in  the  same  manner  over  any  given  region.  If 
the  cups  are  air-tight,  the  flame  is  extinguished  before  the  patient 
feels  the  heat  from  the  burning  alcohol.  When  the  swelling  of  the 
skin  and  underlying  tissues  has  taken  place  to  such  an  extent  as  to 
replace  the  exhausted  air,  the  cups  become  loosened  and  drop  off. 
If,  however,  it  is  desired  to  remove  the  cups  before  this  has  occurred, 
simply  tip  the  cup  to  one  side  and  press  down  the  skin  at  the  edge  of 
the  glass  and  thus  allow  air  to  enter. 


l66  ACUPUNCTURE,   VENESECTION,    SCARIFICATION,    ETC. 

2.  Wet  Cupping. — By  this  method  a  definite  amount  of  blood 
may  be  removed,  each  cup  being  capable  of  abstracting  from  i  to  3 
drams  (4  to  12  c.c).  The  cups  are  first  applied  to  the  region  as  already 
described;  then  with  a  scalpel  parallel  incisions  about  1/3  inch 
(8.5  mm.)  apart  are  made,  care  being  taken  to  incise  the  skin  only, 
for,  if  the  subcutaneous  tissues  are  cut  into,  particles  of  fat  will  be 
drawn  up  into  the  cuts  when  the  cups  are  reappHed.  The  cups  are 
then  immediately  applied  for  the  second  time.  Blood  will  be  drawn 
from  the  scarified  area  into  the  cups  until  the  vacuum  is  exhausted 
and  the  cups  fall  oflf.  If  it  is  desired  to  withdraw  more  blood,  the 
cups  are  emptied  and,  after  washing  away  the  clots  from  the  cut  sur- 
face, they  are  applied  again,  or  hot  fomentations  may  be  employed  to 
encourage  the  bleeding.  When  sufficient  blood  has  been  withdrawn, 
a  sterile  gauze  dressing  is  applied  over  the  scarified  region. 

LEECHING 

Leeching  may  be  employed  for  the  purpose  of  abstracting  blood 
from  contused  or  congested  areas  inaccessible  to  wet  cupping.  It  is 
thus  a  valuable  means  of  local  blood-letting  in  ecchymoses,  or  begin- 
ning acute  inflammation  about  the  eye,  ear,  nose,  gums,  genitals,  etc. 

There  are  two  varieties  of  leech  used  for  this  purpose:  the  small 
American  leech  which  is  capable  of  withdrawing  about  a  dram  (4 
c.c.)  of  blood  and  the  Sweedish  leech  which  will  suck  from  3  to  4 
drams  (4  to  15  c.c).  According  to  the  amount  of  blood  it  is  desired 
to  remove,  from  one  to  six  leeches  may  be  applied  at  one  time.  Only 
those  coming  from  clean,  uncontaminated  water  should  be  used. 

Sites  of  Application. — It  should  be  remembered  that  the  leech 
produces  a  triangular  cut  in  the  skin  which  results  in  a  permanent 
scar,  hence  they  should  not  be  placed  upon  conspicuous  portions  of 
the  body.  They  should  never  be  applied  to  regions  where  there  is 
much  loose  cellular  tissue,  such  as  the  eyelids,  labia,  scrotum,  or  penis, 
for  extensive  ecchymoses  may  be  the  result.  As  their  bite  is  irritat- 
ing, they  should  not  be  applied  directly  to  an  inflamed  area;  instead, 
they  are  to  be  applied  to  the  periphery.  They  should  never  be 
allowed  to  take  hold  of  the  skin  directly  over  a  superficial  artery, 
vein,  or  nerve. 

Leeches  are  generally  applied  to  the  temples  or  the  back  of  the 
neck  in  congestion  or  inflammation  of  the  brain,  to  the  mastoid  and 
in  front  of  the  tragus  in  acute  mastoiditis  and  acute  otitis  media,  to 
the  perineum   when  the  scrotum,  penis,  or  labia  are  the  regions 


LEECHING  167 

alTected,  and  to  the  coccyx  for  the  rehef  of  congested  or  inflamed 
hemorrhoids. 

Asepsis. — To  avoid  infection  the  skin  over  the  region  to  which  the 
leech  is  appHed  should  be  washed  with  soap  and  water.  If  the  part  is 
hairy,  it  should  be  first  shaved. 

Technic. — The  leech  is  applied  to  the  part  and  confined  under 
a  pill-box  or  wineglass  until  it  takes  hold.  A  special  leech-tube  or  a 
test-tube  may  be  employed  for  this  purpose,  in  which  case  the  leech 
is  placed  in  the  tube  tail  or  large  end  first  and  the  tube  is  then 
inverted  so  that  the  leech's  head  comes  in  contact  with  the  skin. 
This  may  be  removed  as  soon  as  the  leech  takes  hold,  but,  in  employ- 
ing leeches  about  the  orifices  of  mucous  cavities,  they  should  always  be 
confined  so  as  to  prevent  their  escape  into  the  interior.  If  the 
leeches  are  removed  from  the  water  an  hour  or  so  before  using,  they 
will  take  hold  more  readily.  Making  a  puncture  in  the  skin  and 
applying  the  leech  to  the  bleeding  spot  or  rubbing  the  skin  with 
sweetened  water  or  milk  will  cause  the  leech  to  take  hold,  if  it  does  not 
seem  inclined  to  do  so.  When  once  the  leech  has  begun  to  draw 
blood,  it  should  not  be  pulled  off — it  will  drop  off  when  filled.  If  it  is 
desirable,  however,  to  remove  it. sooner,  sprinkling  salt  over  it  will 
induce  it  to  let  go. 

By  applying  hot  fomentations  to  the  part  after  the  removal  of 
the  leech  bleeding  can  be  encouraged  and  often  an  ounce  (30  c.c.)  or 
more  of  blood  may  be  withdrawn  in  this  way.  After  removal  of  the 
leech  the  bite  should  be  bathed  with  sterile  water  and  a  small  gauze 
dressing  applied. 

Sometimes  a  considerable  and  troublesome  bleeding  continues 
from  the  leech  bite,  due  to  the  fact  that  the  tissues  become  infiltrated 
with  material  excreted  from  the  throat  of  the  leech  which  prevents 
coagulation  of  the  blood.  The  bleeding  can  usually  be  controlled, 
however,  by  compression  or  by  applying  a  piece  of  cotton  saturated 
with  some  styptic,  as  a  solution  of  i  to  1000  adrenalin  chlorid,  alum, 
or  tannic  acid.  The  use  of  the  actual  cautery  or  passing  a  harelip 
pin  or  needle  beneath  the  bite  and  winding  a  thread  about  the  two 
ends  so  as  to  constrict  the  part  are  also  advised.  Failing  in  these 
measures,  the  bite  should  be  excised  and  the  tissues  sutured. 

The  Artificial  Leech. — This  apparatus  may  be  employed  instead 
of  live  leeches.  It  consists  of  a  small  cupping  apparatus  combined 
with  a  scarifier  (Fig.  147).  The  latter  is  in  the  form  of  a  small  steel 
cylinder  containing  a  circular  lancet  propelled  by  a  cord  or  a  spring. 
The  skin  is  first  scarified,  by  drawing  upon  the  cord  which  causes  the 


l68  ACUPUNCTURE,  VENESECTION,    SCARIFICATION,   ETC. 


Fig.  147. — Artificial  leech. 


Fig.   148. — Application  of  the  artificial  leech  to  the  mastoid.      (After  Ballenger.) 
First  step,  showing  the  method  of  scarifj'^ing. 


Fig.   149. — Apphcation  of  the  artificial  leech  to  the  mastoid.      (After  Ballenger.) 
Second  step,  withdrawing  blood. 


LEECHING  l6g 

lancet  to  rapidly  rotate,  as  shown  in  the  accompanying  illustration 
(Fig.  148),  the  blades  of  the  instrument  being  adjusted  so  as  to  cut  to 
the  desired  depth.  Then  the  cupping  tube  is  apphed  and  blood 
abstracted  by  withdrawing  the  piston  and  creating  a  vacuum  (Fig. 
149) .  With  this  instrument  as  much  as  i  ounce  (30  c.c.)  of  blood  may 
be  withdrawn. 


CHAPTER  VII 

HYPODERMIC  AND  INTRAMUSCULAR  INJECTIONS, 
THE  ADMINISTRATION  OF  SALVARSAN  AND  NEO- 
SALVARSAN,  THE  ADMINISTRATION  OF  DIPHTHE- 
RIA ANTITOXIN,  VACCINATION 

THE  HYPODERMIC  AND  INTRAMUSCULAR  INJECTION   OF 

DRUGS 

Drugs  may  be  administered  by  injection  into  the  subcutaneous  or 
muscular  tissues  when  a  rapid  effect  is  desired,  or  when,  for  any 
reason,  medication  by  the  mouth  is  undesirable  or  is  contraindicated. 
The  injection  of  soluble,  nonirritating  substances  is  made  into  the 
subcutaneous  tissues,  from  which  the  absorption  is  very  rapid;  but 
when  the  solution  is  insoluble  or  irritating,  so  that  its  presence 
in  sensitive  tissues  would  produce  pain,  it  had  best  be  given 
intramuscularly. 

The  advantages  of  hypodermic  medication,  besides  the  prompt- 
ness of  the  effects  obtained,  consist  in  aft'ording  a  method  whereby 
it  is  possible  to  administer  remedies  in  the  presence  of  nausea  and 
vomiting,  or  inability  or  unwillingness  on  the  part  of  the  patient  to 
swallow;  furthermore,  the  absorption  of  the  drug  is  not  dependent 
upon  the  functional  activity  of  the  gastrointestinal  tract. 

The  Hypodermic  Syringe. — The  ordinary  hypodermic  syringe 
consists  of  a  glass  barrel  protected  by  a  metal  case  and  furnished  with 


e 
Fig.    150. — -Ordinary  glass  and  metal  hypodermic  syringe. 

a  leather-covered  piston  (Fig.  150).  Such  syringes,  however,  are 
difficult  to  keep  clean  and,  if  they  are  frequently  boiled,  the  leather 
packing  soon  dries  out  and  becomes  inefficient  unless  carefully  at- 
tended to.  Syringes  of  solid  metal  (Fig.  151)  or  those  consisting  of 
a  glass  barrel  and  soHd  glass  piston,  as  the  Luer  (Fig.  152),  or  with 
an  asbestos-covered  piston,  as  the  "Sub-Q,"  will  be  found  preferable. 

170 


HYPODERMIC    AND    INTRAMUSCULAR    INJECTION    OF    DRUGS       171 

and  may  be  easily  cleaned  and  repeatedly  boiled  without  harm.  A 
syringe  with  a  capacity  of  3oTn,  (2  c.c.)  is  amply  large  for  ordinary 
use. 

The  needles  should  be  as  tine  as  possible  (28  to  27  gauge)  and 
very  sharp,  and  for  injection  beneath  the  skin  they  should  be  about 
I  inch  (2.5  cm.)  in  length.  For  the  administration  of  liquids  of  a 
heavy  consistency  a  needle  of  somewhat  larger  caliber  will  be  required. 
For  intramuscular  injections,  the  needle  should  be  i  1/2  to  2  inches 
(4  to  5  cm.)  long,  and,  if  one  of  the  insoluble  preparations  of  mercury 
is  employed,   the  caliber  of  the  needle  should  be  correspondingly 


Fig.    151. — All  metal  hypodermic  syringe. 

large.  To  prevent  the  needles  rusting  and  the  lumen  becoming 
plugged,  they  should  be  first  well  cleaned  out  with  water  after  using, 
followed  by  alcohol  and  ether  to  remove  any  remaining  fluid  from  the 
interior  that  might  cause  rusting,  and,  finally,  they  should  be  put 
away  with  a  fine  wire  inserted  in  the  lumen. 

Preparation  of  the  Solution. — The  drugs  most  frequently  used  for 
hypodermic  medication  are  morphin,  atropin,  strychnin,  hyoscin, 
pilocarpin,  cafi'ein,  cocain,  apomorphin,  quinin,  mercury,  digitalis, 
ergotin,  nitroglycerin,  adrenalin,  alcohol,  ether,  etc.     As  the  majority 


Fig.   152. — Luer's  hypodermic  syringe. 

of  these  are  either  very  powerful  or  poisonous,  the  dose  should  be 
accurately  measured  in  every  case. 

The  solution  employed  for  the  injection  should  always  be  sterile 
and  preferably  freshly  prepared.  The  strength  of  the  solution  is  also 
important,  for,  if  too  concentrated,  it  may  prove  irritating,  while, 
if  greatly  diluted,  the  bulk  of  solution  necessary  for  the  injection 
becomes  objectionable.  Most  of  the  drugs  for  hypodermic  use  may 
be  obtained  in  the  form  of  soluble  tablets  which  are  dissolved  in  5 
to  icTtl  (o-3  to  0.6  c.c.)  of  boiled  water  when  required  for  use.  Sterile 
solutions  of  the  drugs,  however,  may  be  obtained  in  hermetically 


172 


HYPODERMIC   AND    INTRAMUSCULAR    INJECTIONS,    ETC. 


sealed  glass  ampoules,  each  containing  suflScient  for  one  dose.  The 
solution  must  be  as  nearly  neutral  as  possible;  irritating  solutions  or 
strongly  alcoholic  preparations  should  be  avoided  on  account  of  the 
danger  of  subsequent  sloughing  at  the  seat  of  injection.  When 
whisky  or  brandy  is  employed,  it  is,  therefore,  well  to  dilute  them 
with  an  equal  amount  of  water  before  using.  Insoluble  preparations, 
as  the  salicylate  of  mercury,  for  example,  are  best  administered  in 
some  sterile  oil  as  albolene  or  benzoinol. 

Sites  for  Injection. — For  ordinary  injections  the  least  sensitive 
portions  of  the  body  provided  with  plenty  of  cellular  tissue  are 


Fig.   153. — Sites  for  hypodermic  injections. 


selected,  the  spot  chosen,  of  course,  being  distant  from  the  immediate 
neighborhood  of  large  blood-vessels  or  nerves,  bony  prominences,  or 
inflamed  areas.  The  common  sites  are  the  outer  surfaces  of  the  arm, 
forearm,  thighs,  or  the  buttocks. 

For  deep  intramuscular  injections  of  drugs  not  rapidly  absorbed 
an  area  in  the  gluteal  region,  lying  between  the  gluteal  fold  below  and 
a  horizontal  line  through  the  upper  margin  of  the  great  trochanter, 
is  usually  chosen  (Fig.  153).  Where  numerous  injections  are  given 
care  should  be  taken  to  alternate  between  the  two  sides  and  to  avoid 


HYPODERMIC    AND    INTRAMUSCULAR    INJECTION    OF   DRUGS       1 73 

repeating  the  injections  in  the  same  spot  each  time.  Meltzer 
{Medical  Record,  March  25,  191 1)  recommends  that  intramuscular 
injections  be  made  in  the  lumbar  muscles,  claiming  that  absorption 
is  more  rapid  than  from  the  glutei.  The  spot  chosen  is  at  the  junc- 
tion of  the  inner  and  middle  thirds  of  a  line  uniting  the  highest 


Fig.   154. — Showing  the  method  of  giving  a  hypodermic  injection. 

points  of  the  iliac  crest  with  the  third  or  fourth  lumbar  spinous 
process. 

Position  of  Patient. — For  a  deep  intramuscular  injection  the 
patient  lies  upon  the  opposite  side  or  upon  the  abdomen. 

Asepsis. — The  strictest  regard  as  to  cleanliness  should  always 
be  observed.     The  needle  and  syringe  should  be  boiled  or  at  least 


Fig.   155. — Deep  intramuscular  injection.     First  step,  inserting  the  needle. 

immersed  in  some  antiseptic  solution  before  use,  and  the  skin  at 
the  site  of  the  injection  should  be  painted  with  tincture  of  iodin  or 
rubbed  clean  with  a  piece  of  cotton  or  gauze  saturated  with  alcohol. 
Technic.^ — The  required  amount  of  solution  is  drawn  into  the 
barrel  of  the  syringe  with  the  needle  in  place  and  any  air  is  expelled 
by  elevating  the  needle  end  and  depressing  the  piston.     The  skin 


174 


HYPODERMIC    AND    INTRAMUSCULAR    INJECTIONS,    ETC 


over  the  site  of  the  proposed  injection  is  then  pinched  up  between 
the  thumb  and  forefinger  of  the  left  hand,  while  with  the  right  hand 
the  needle  is  quickly  thrust  at  an  angle  of  45  degrees  into  the  sub- 


FiG.   156. — Deep    intramuscular    injection.     Second    step,    showing    the     syringe 
removed  and  inspection  of  the  needle  for  the  flow  of  blood. 

cutaneous  tissues  at  the  base  of  this  fold  (Fig.  154).  If  the  needle 
is  sharp  and  it  be  quickly  plunged  through  the  skin,  but  little,  if  any, 
pain  will  be  experienced.  The  solution  should  be  injected  slowly  to 
avoid  too  sudden  distention  of   the   tissues.     When  the   required 


Fig.   157. — Deep  intramuscular  injection.     Third  step,  injecting  the  solution. 

amount  has  been  introduced,  the  needle  is  quickly  withdrawn,  and 
the  finger  is  placed  over  the  site  of  puncture,  and  gentle  massage  is 
practised  for  a  moment  or  two  to  diffuse  the  solution. 


ADMINISTRATION    OF    SALVARSAN   AND    NEOSALVARSAN  1 75 

In  giving  a  deep  intramuscular  injection,  the  skin  over  the  chosen 
site  is  held  tense  by  the  fingers  of  the  left  hand,  and  the  needle  is 
steadily  forced  through  the  skin  and  subcutaneous  tissues  directly 
into  the  glutei  muscles  up  to  its  hilt  (Fig.  155).  As  soon  as  the  needle 
is  in  place,  it  is  advisable  to  remove  the  syringe  and  observe  whether 
there  is  any  flow  of  blood  from  the  needle  (Fig.  156);  if  so,  a  new 
puncture  should  be  made.  Observance  of  this  precaution  will 
obviate  injecting  the  solution  into  the  blood  current  should  the  needle 
point  penetrate  some  vein.  The  solution  is  then  injected  slowly 
(Fig.  157),  and  at  the  completion  of  the  operation  the  site  of  punc- 
ture is  sealed  with  collodion  or  by  means  of  a  small  piece  of  adhesive 
plaster. 

THE  ADMINISTRATION  OF  SALVARSAN  AND 
NEOSALVARSAN 

SALVARSAN 

Salvarsan,  or  "606,"  is  a  yellowish  crystalline  powder  containing 
about  1/3  of  its  weight  of  arsenic.  It  was  introduced  by  Ehrlich 
in  1 9 10  for  the  cure  of  syphilis  after  years  of  experimental  work 
upon  animals  with  spirillicidal  drugs.  Although  salvarsan  has 
proved  a  most  important  addition  to  therapeutics,  we  have 
been  compelled  to  revise  materially  our  early  conceptions  of  its 
value.  It  was  originally  claimed  that  one  large  dose  would  entirely 
destroy  the  spirochetes  of  syphilis,  but  unfortunately  this  early  prom- 
ise has  not  been  realized  in  the  majority  of  cases.  There  is  no 
doubt  that  this  new  remedy  is  a  powerful  spirochetal  poison  and  it 
unquestionably  causes  certain  of  the  manifestations  of  syphilis  to 
disappear  very  rapidly,  but  whether  the  results  obtained  from  its 
use,  even  in  repeated  doses,  are  permanent  or  only  temporary  will 
require  many  years  to  establish.  Owing  to  numerous  relapses  that 
have  followed  single  injections,  it  is  now  generally  agreed  that  a  single 
dose  is  not  curative.  At  the  present  time,  the  majority  of  authori- 
ties advise  that  the  injection  should  be  repeated  one  or  more  times 
and  that  its  use  should  be  followed  by  the  administration  of  mercury 
for  the  usual  period. 

Salvarsan  is  indicated  in  all  stages  of  syphilis.  It  gives  the  best 
results,  however,  the  earlier  in  the  disease  it  is  used,  being  more 
rapidly  effective  than  mercury,  especially  upon  mucous  lesions,  and 
causing  the  Wassermann  reaction  to  become  more  quickly  negative. 
So  that  in  the  primary  and  early  secondary  stages  the  most  brilliant 


176  HYPODERMIC  AND   INTRAMUSCULAR   INJECTIONS,   ETC. 

results  are  obtained,  while  in  the  late  secondary  and  tertiary  stages 
it  becomes  more  difficult  to  eradicate  the  infection.  It  has  little  or 
no  effect  in  well  marked  locomotor  ataxia  and  paresis.^  It  is  contra- 
indicated  in  advanced  degenerative  processes  of  the  central  nervous 
system  and  in  long-standing  cardiac  and  vascular  degenerations, 
and  in  nonsyphilitic  retinal  and  optic  nerve  afTections.  Syphilitic 
eye  and  ear  diseases,  however,  are  not  contraindications  to  its  use. 
Any  known  idiosyncrasy  against  arsenic  should  lead  to  great  caution 
in  its  use. 

Salvarsan  has  also  been  employed  in  the  treatment  of  other  diseases 
due  to  spirilla  with  excellent  results.  In  relapsing  fever,  filariasis,  yaws, 
and  in  some  forms  of  malaria,  it  has  proved  very  efficacious,  frequently 
one  injection  sufficing  to  produce  a  cure.  It  has  also  been  tried  in 
leukemia,  splenic  anemia,  leprosy,  tuberculosis,  and  pellagra  with 
questionable  results.  In  certain  of  the  infectious  diseases  in  which 
it  has  been  used,  as  scarlet  fever,  small-pox,  anthrax,  glanders,  it  is 
too  early  to  give  a  positive  opinion  as  to  its  value. 

Salvarsan  was  at  first  given  subcutaneously.  Then  intramus- 
cular injections  were  substituted,  but  these  proved  very  painful. 
The  drug  was  not  always  absorbed,  and  at  times  caused  great  irri- 
tation at  the  site  of  injection  and,  in  some  cases,  sloughs  that  were 
very  slow  in  separating.  At  the  present  time  the  intravenous 
method  of  administration  is  generally  adopted. 

Its  administration  is  likely  to  be  followed  in  from  one  to  six  hours 
by  a  systemic  reaction,  consisting  of  a  chill,  a  rise  of  i  to  2  degrees  in 
the  temperature,  gastric  irritation,  and  diarrhoea.  These  symptoms, 
however,  are  not  always  present,  and  the  temperature  and  chill  are 
less  likely  to  occur  if  freshly  distilled  water  is  used  in  the  preparation 
of  the  solution.  In  exceptional  cases,  following  an  injection,  or  as 
late  as  one  or  two  days  after,  the  patient  becomes  quite  sick;  he  has 

1  Recently,  Swift  and  Ellis  of  the  Rockefeller  Institute  have  developed  a  new 
line  of  treatment  for  syphilis  of  the  central  nervous  system,  employing  intra- 
spinous  injections  of  salvarsanized  serum.  The  results  in  the  cases  so  far 
reported  have  been  most  encouraging,  and  it  would  seem  that  in  some  cases  of 
tabes  and  paresis  a  cure  may  be  effected  and  even  in  well-marked  cases  the 
disease  may  be  checked  by  the  intraspinous  serum  treatment. 

The  technic  is  briefly  as  follows:  Salvarsan  is  given  intravenously,  usually  in  a 
maximum  dose,  and  an  hour  later  10  drams  (40  c  c.)  of  blood  are  withdrawn  from 
the  patient  by  venous  puncture  into  a  bottle-shaped  centrifuge  tube.  This  is 
allowed  to  coagulate,  after  which  it  is  centrifuged.  The  next  day  3  drams 
(12  c.c.)  of  the  resulting  clear  serum  are  removed  by  means  of  a  pipette, 
mixed  with  5  drams  (18  c.c.)  of  sterile  normal  salt  solution,  and  heated  for  half 
an  hour  at  a  temperature  of  132.8°  F.  (56°  C).  This  serum  is  then  injected  by 
lumbar  puncture,  after  withdrawing  a  small  quantity  of  the  cerebrospinal  fluid. 


ADMINISTRATION   OP    SALVARSAN   AND   NEOSALVARSAN 


177 


headache,    vertigo,    severe    gastric    irritation,    high    temperature, 
loose  stools,  and  disturbance  of  circulation.    A  transient  albumi- 
nuria may  be  present  during  elimination  of  the  drug.     In  some  cases 
death  has  resulted  with  all  the  symptoms  of  arsenical  poisoning. 
Apparatus. — There  will  be  required  (i)  a  graduated  glass  cylinder 


10 

Fig.  158. — Apparatus  for  intravenous  injection  of  salvarsan.  i,  Graduated 
reservoir,  rubber  tubing,  and  vein  needle;  2,  graduate  and  glass  rod  for  mixing 
the  solution;  3,  decanter  for  distilled  water;  4,  glass  funnel;  5,  medicine  dropper; 
6,  bottle  of  sodium  hydroxid  solution;  7,  tube  of  salvarsan;  8,  file;  9,  catheter  for 
constricting  arm;   10,  artery  clamp, 

with  a  capacity  of  about  10  ounces  (300  cc),  (2)  4  feet  (120  cm.)  of 
rubber  tubing  with  a  short  piece  of  glass  tube  inserted  in  it  to  allow 
detection  of  any  air  bubbles,  (3)  a  Schreiber  infusion  needle,  2  1/2 
inches (6  cm.)  long  and  of  No.  18  caliber,  (4)  a  glass  decanter  for  dis- 
tilled water,  (5)  a  glass  graduate  for  mixing  the  solution,  (6)  a  funnel 


Fig,   159. — Enlarged  view  of  vein  needle, 

in  which  is  placed  filter  paper  or  sterile  cotton  to  filter  the  solution 
through,  (7)  a  glass  stoppered  bottle  containing  a  solution  of  15  per 
cent,  sodium  hydroxid,  (8)  a  medicine  dropper,  (9)  a  glass  stirring 
rod,  (10)  a  catheter  and  artery  clamp  for  constricting  the  arm  of  the 
patient,  (11)  a  tube  of  salvarsan  and  a  file  to  open  it  with  (Fig,  158). 


178  HYPODERMIC    AND    INTRAMUSCULAR    INJECTIONS,    ETC 

In  addition,  it  is  well  to  have  at  hand  a  scalpel  and  a  cocain 
syringe  in  case  it  is  necessary  to  expose  the  vein  before  inserting  the 
needle. 

Asepsis. — The  apparatus  is  sterilized  by  boiling.  The  tube  con- 
taining the  salvarsan  and  the  file  are  placed  in  alcohol,  and  the 
operator's  hands  are  prepared  as  carefully  as  for  any  operation. 

Preparation  of  the  Solution. — It  has  been  found  that  much  of 
the  immediate  systemic  reaction  is  due  to  impurities  in  the  water, 
for  this  reason  only  freshly  distilled  sterile  water  should  be  employed 
in  the  preparation  of  the  solution.  The  ampoule  of  salvarsan 
is  dried  off,  the  glass  is  nicked  with  the  file,  the  tube  is  broken 
open,  and  its  contents  are  poured  into  30  to  40  c.c.  (i  to  i  1/2 
ounces)  of  hot  sterile  distilled  water  previously  placed  in  the 
mixing  glass.  The  solution  is  then  shaken  or  stirred  until  all  the  drug 
is  thoroughly  dissolved.  To  the  resulting  clear  acid  solution  is 
added  drop  by  drop  the  15  per  cent,  sodium  hydroxid  solution  b\- 
means  of  the  dropper,  the  solution  being  shaken  after  each  drop  is 
added.  This  causes  a  precipitate  to  form,  which  dissolves  as  the 
solution  becomes  alkaline.  It  requires  about  20  drops  of  the  sodium 
hydroxid  solution  to  render  a  mixture  containing  0.5  gm.  (7  1/2 
gr.)  of  salvarsan  perfectly  clear.  Having  obtained  an  absolutely 
clear  solution,  it  is  diluted  with  sterile  0.5  per  cent,  saline  solution, 
made  from  chemically  pure  sodium  chlorid  and  sterile,  freshly  distilled 
water,  up  to  250  c.c.  (8  ounces)  if,  for  example,  0.5  gm.  (7  1/2  gr.) 
is  the  dose,  that  is,  50  c.c.  (i  2/7,  ounces)  of  fluid  is  used  for  every 
0.1  gm.  (i  1/2  gr.)  of  salvarsan.  The  solution  is  now  ready  for  use 
and  is  finally  filtered  through  sterile  cotton  placed  in  a  funnel  into 
the  intravenous  apparatus. 

Temperature  of  the  Solution. — The  solution  is  given  at  about  a 
temperature  of  105°  F.  (41°  C). 

Dosage. — An  average  dose  for  men  is  0,4  to  0.5  gm.  (6  to  7  1/2 
gr.),  for  women  0.3  to  0.4  gm.  (4  1/2  to  6  gr.),  for  children  0.2  to 
0.3  gm.  (3  to  4  1/2  gr.),  and  for  infants  0.02  to  0.05  gm.  (1/3  to  3/4 
gr.).  In  this  country  it  is  becoming  customary  to  employ  smaller 
initial  doses,  that  is,  0.2  and  0.3  gm.  (3  and  4  1/2  gr.)  doses  and,  if 
no  unpleasant  symptoms  follow,  the  second  dose  may  be  increased 
0.1  gm.  (i  1/2  gr.). 

Repetition  of  the  Dose. — The  injection  may  be  repeated  in  from 
one  to  four  weeks,  depending  upon  the  reaction  produced  and  the 
effect  on  the  lesions.     In  the  early  cases  from  three  to  four  injections 


ADMINISTRATION    OF    SALVARSAN    AND    NEOSALVARSAX  1 79 

are  usually  given,  and  in  the  late  cases  from  five  to  six,  or  more,  un- 
til the  Wassermann  reaction  remains  negative. 

Site  of  Injection. — Some  one  of  the  prominent  veins  on  the 
anterior  aspect  of  the  arm  in  front  of  the  elbow-joint — preferably 
the  median  basilic — is  chosen  for  the  injection. 

Position  of  the  Patient. — The  injection  should  be  given  with  the 
patient  in  the  recumbent  posture. 

Preparations  of  Patient. — All  tight  clothing  should  be  removed 
from  the  arm  selected  for  the  infusion.  The  site  of  puncture  is 
painted  with  tincture  of  iodin,  and  the  rubber  catheter  is  secured 
about  the  arm  with  sufficient  tension  to  make  the  veins  stand  out 
prominently. 

Technic. — With  the  tourniquet  properly  apphed  about  the  fore- 
arm, the  operator  identifies  the  vein  into  which  he  wishes  to  insert 
the  needle  and  instructs   the  patient   to  work  his  fingers  until  the 


Fig.   160. —  ■Method  of  inserting  needle  into  the  vein. 

vein  becomes  quite  prominent.  The  needle,  held  almost  flat  with 
the  skin  surface,  is  then  thrust  through  the  skin  into  the  vein  toward 
the  axilla  (Fig.  i6o).  The  successful  entrance  into  the  vein  is  indi- 
cated by  a  flow  of  blood  from  the  end  of  the  needle.  Care  must  be 
taken  to  insert  the  needle  into  the  vein  and  not  through  the  opposite 
wall  of  the  vein.  If  the  needle  is  held  almost  parallel  with  the  sur- 
face of  the  arm,  this  accident  is  not  likely  to  occur.  If  there  is  any 
difficulty  in  finding  the  vein,  it  should  be  exposed  by  a  small  trans- 
verse nick  through  the  skin  under  infiltration  anesthesia  and  the 
needle  inserted  by  sight.  The  tourniquet  is  then  removed  from  the 
patient's  arm,  and,  after  seeing  that  all  the  air  is  expelled  from 
the  tubing  of  the  intravenous  apparatus,  the  latter  is  connected 


i8o 


HYPODERMIC    AND    INTRAMUSCULAR    IN'JECTIOXS,    ETC 


with  the  needle,  and  the  solution  is  permitted  to  flow  into  the  vein. 
The  solution  is  injected  very  cautiously  at  first  until  it  is  certain 
that  it  is  entering  the  vein  and  not  the  surrounding  tissues,  or  a 
test  injection  of  a  small  amount  of  normal  salt  solution  is  made. 
Any  leakage  of  the  salvarsan  solution  into  the  tissues  causes 
a  severe  burning  pain  and  necessitates  the  immediate  stoppage  of 
the  injection.     During  the  injection  the  reservoir  is  raised  24  to 


Fig.   161. — Method  of  giving  salvarsan  intravenously. 

30  inches  (60  to  75  cm.)  above  the  level  of  the  patient.  It  takes 
about  ten  minutes  for  the  entire  quantity  of  solution  to  flow 
into  the  vein:  at  the  completion  of  the  operation  the  needle  is 
quickly  removed  and  a  sterile  pad  is  placed  over  the  site  of  puncture 
and  is  secured  by  a  few  turns  of  a  bandage. 

While  some  operators  administer  salvarsan  intravenously  in  their 
ofl5ce.  the  patient  being  required  to  go  home  immediately  and  remain 


NEOSALVARSAN 


Ibl 


quiet  for  several  hours,  there  is  considerable  risk  connected  with  such 
a  procedure,  and  it  is  safer  to  give  the  first  injection,  at  any  rate,  in 
the  patient's  home  or  at  a  hospital,  following  which  the  patient  is 
required  to  remain  quiet  in  bed  for  twelve  hours. 

NEOSALVARSAN 

Lately  a  new  and  very  soluble  form  of  salvarsan  has  been  intro- 
duced under  the  name  of  neosalvarsan,  or  "914."  The  general  prop- 
erties of  neosalvarsan  are  similar  to  those  of  salvarsan  and  it  is 
claimed  to  be  just  as  efficacious.  It,  however,  possesses  certain 
decided  advantages  over  salvarsan  in  that  it  is  better  tolerated  and 
is  less  often  followed  by  a  systemic  reaction,  so  that  larger  doses 
can  be  employed  and  the  dose  may  be  repeated  more  frequently. 
Furthermore,  the  preparation  of  the  solution  is  very  simple,  the  drug 
being  quite  soluble  in  water  and  not  requiring  to  be  neutralized  with 
caustic  soda, 

Neosalvarsan  is  given  intravenously  or  by  intramuscular  injec- 
tion— preferably  by  the  former  method. 

Apparatus. — For  the  intravenous  administration  of  dilute  solu- 
tions of  neosalvarsan  the  same  apparatus  described  for  the  adminis- 
tration of  salvarsan  (page  177)  will  be  required. 


1  K  3  » 

Fig.  162. — Apparatus  for  intramuscular  and  intravenous  injections  of  con- 
centrated solutions  of  neosalvarsan.  i,  Decanter  of  distilled  water;  2,  medicine 
glass;  3,  all  glass  syringe  and  needle;  4,  tube  of  neosalvarsan;  5,  small  file. 

For  the  intravenous  administration  of  concentrated  solutions  and 
for  intramuscular  injections  there  will  be  required:  (i)  a  Luer  or 
Record  syringe  with  a  capacity  of  10  to  20  c.c.  (2  1/2  to  5  dr.),  (2) 
a  needle  about  2  1/2  inches  (6  cm.)  long  and  of  No.  18  caliber,  (3)  a 
glass  decanter  for  distilled  water,  (4)  a  medicine  glass  for  mixing  the 
solution,  (5)  a  tube  of  neosalvarsan  and  a  file  to  open  it  with,  and 


1 82  HYPODERMIC   AND   INTRAMUSCULAR   INJECTIONS,    ETC. 

(6)  a  glass  rod  for  stirring  (Fig.  162).  In  addition,  for  an  intra- 
venous injection  a  tourniquet  will  be  required  . 

Asepsis. — The  apparatus  and  instruments  are  sterilized  by 
boiling,  the  operator's  hands  are  cleansed  as  for  any  operation,  and 
the  tube  of  neosalvarsan  and  the  file  are  immersed  in  alcohol. 

Preparation  of  the  Solution. — For  intravenous  injections  a  dilute 
or  a  concentrated  solution  may  be  used.  The  former  is  prepared  by 
dissolving  each  0.15  gm.  (2  1/3  gr.)  of  salvarsan  in  25  c.c.  (6  3/4  dr.) 
of  freshly  distilled  sterile  water.  The  water  should  not  be  heated, 
but  should  be  at  about  the  temperature  of  the  room,  that  is,  68°  to 
71.6°  F.  (20°  to  22°  C). 

The  concentrated  intravenous  solution  is  prepared  by  dissolving 
0.45  to  0.6  gm.  (6  3/4  to  9  gr.)  of  neosalvarsan  in  10  c.c.  (2  3/4  dr.) 
of  freshly  distilled  sterile  water,  or  0.75  to  0.9  gm.  (11  1/2  to  14  gr.) 
of  neosalvarsan  in  15  c.c.  (4  dr.)  oi  freshly  distilled  sterile  water. 

The  solution  for  an  intramuscular  injection  is  prepared  by  dis- 
solving each  0.15  gm.  (2  1/3  gr.)  of  neosalvarsan  in  about  3  c.c. 
(48  minims)    of  freshly  distilled  sterile  water. 

Temperature  of  the  Solution. — The  solution  should  not  be  injected 
at  a  higher  temperature  than  68°  to  71.6°  F.  (  20°  to  22°  C). 

Dosage. — The  average  dose  of  neosalvarsan  for  men  is  0.6  to 
0.75  gm.  (9  to  II  1/2  gr.),  for  women  0.45  to  0.6  gm.  (6  3/4  to  9 
gr.),  for  children  0.15  to  0.3  gm.  (2  1/3  to  4  2/3  gr.),  and  for  infants 
0.05  gm.  (3/4  gr.). 

Repetition  of  the  Dose. — Injections  of  neosalvarsan  may  be 
repeated  at  intervals  of  from  3  to  7  days. 

Site  of  Injection. — Intravenous  injections  are  given  in  the  median 
basilic  or  some  other  prominent  vein  at  the  bend  of  the  elbow. 

Intramuscular  injections  are  given  in  the  gluteal  region  (see 
page  172). 

Position  of  Patient. — For  an  intravenous  injection  the  patient 
should  be  recumbent;  for  an  intramuscular  injection  the  patient 
lies  upon  the  abdomen. 

Preparation  of  the  Patient. — If  the  intravenous  method  is  em- 
ployed, all  constricting  clothing  should  be  removed  from  the  patient's 
arm.     The  site  of  puncture  is  well  painted  with  tincture  of  iodin. 

Technic. — (i)  Intravenous  Administration.  The  technic  differs 
in  no  material  way  from  that  already  described  for  the  administra- 
tion of  salvarsan  (see  page  179).  When  the  concentrated  solution 
is  employed,  however,  the  injection  is  more  conveniently  made  with 
a  syringe  instead  of  a  gravity  apparatus. 


ADMINISTRATION    OF    DIPHTHERIA   ANTITOXIN  1 83 

(2)  Intramuscular  Injecti&n. — A  spot  in  the  gluteal  region  dis- 
tant from  the  course  of  the  sciatic  nerve  is  chosen,  and  the  needle  is 
thrust  deeply  into  the  muscle.  If  there  is  no  bleeding,  about  60 
drops  of  0.5  per  cent,  novocain  solution  is  injected  into  the  region  in 
order  to  diminish  the  sensibility.  Then,  after  waiting  a  few  moments, 
the  desired  quantity  of  neosalvarsan  is  injected  through  the  same 
needle.  The  site  of  puncture  is  finally  sealed  with  a  piece  of  adhesive 
plaster.  (The  technic  of  intramuscular  injections  is  more  fully 
described  on  page  175.)  Following  the  injection,  the  patient  is  kept 
in  the  recumbent  position  on  his  side  or  abdomen  for  15  to  20 
minutes. 


THE  ADMINISTRATION  OF  DIPHTHERIA  ANTITOXIN 

Antitoxin  is  now  almost  universally  used  in  the  treatment  of  diph- 
theria, and  its  administration  is  a  procedure  with  which  all  physicians 
should  be  familiar.  It  has  enormously  reduced  the  mortality  from 
this  disease,  and,  if  the  serum  is  of  reliable  quality,  its  use  is  without 
danger.  The  diphtheria  bacilli  are  not  killed  by  the  antitoxin,  but 
the  toxins  are  neutralized  and  a  condition  is  produced  in  the  blood 
which  inhibits  the  growth  of  the  bacilli  so  that  they  gradually  dis- 
appear. 

The  Serum. — As  the  serum  is  liable  to  be  contaminated  it  should 
always  be  obtained  from  an  unquestionable  source.  Antitoxin  of 
the  greatest  concentration,  that  is,  containing  as  little  serum  and  as 
many  units^  of  antitoxin  as  is  possible,  should  be  used  in  preference, 
as  smaller  amounts  at  a  dose  will  be  required  and  joint  pains,  skin 
eruptions,  etc. — symptoms  which  are  now  considered  to  be  due  to  the 
horse  serum  and  not  the  antitoxin — will  be  avoided. 

Dosage. — There  is  no  definite  rule  for  fixing  the  dose.  It  is  known 
how  much  antitoxin  is  required  to  neutralize  a  given  amount  of  toxin, 
but  in  practice  there  is  no  method  of  estimating  the  latter  in  any  given 
case.  Conclusions  drawn  from  experience  and  clinical  studies  give 
the  only  practical  guides.  The  dose  should  always  be  large,  however, 
for  the  serum  is  harmless  and  it  is  better  to  administer  too  much  than 
not  enough.  The  average  dose  advised  by  the  New  York  Health 
Department  is  5000  units,  repeated  the  following  day  if  the  condition 
of  the  patient  has  not  improved.  According  to  Holt ''  for  a  child  over 
two  years,  an  initial  dose  for  a  severe  attack,  including  all  laryngeal 

^  The  strength  of  the  serum  is  measured  in  units,  a  unit  being  the  amount  of 
antitoxin  necessary  to  neutralize  in  a  guinea-pig  lOO  fatal  doses  of  diphtheria. 


1 84 


HYPODERMIC   AND   INTRAMUSCULAR   INJECTIONS,    ETC. 


cases,  should  not  be  less  than  4000  to  5000  units;  and  the  dose  should 
be  repeated  in  six  or  eight  hours  provided  no  improvement  is  seen. 
Children  under  two  years  should  receive  from  2000  to  3000  units. 
Cases  of  exceptional  severity  where  the  injection  is  given  late  should 
receive  from  8000  to  10,000  units,  to  be  repeated  in  from  six  to  eight 
hours  if  the  progress  of  the  disease  is  unfavorable.  Mild  cases  should 
receive  from  2000  to  3000  units  as  an  initial  dose,  a  second  being  rarely 
required." 

An  immunizing  dose  should  be  given  to  those  exposed  to  the  con- 
tagion in  all  cases,  1000  units  for  a  child  under  two  years  old,  and  for 
older  children  and  adults  a  larger  dose  (2000  units)  may  be  adminis- 
tered. The  immunity  thus  furnished  is  not  permanent,  however, 
lasting  only  three  or  four  weeks. 

Time  of  Administration. — Antitoxin  should  be  given  as  soon  as  a 
clinical  diagnosis  is  made,  not  waiting  for  a  bacteriological  examina- 
tion. There  are  no  contraindications  to  its  use  in  the  presence  of 
urgent  symptoms.  No  matter  how  late  a  case  is  seen,  an  injection 
should  be  given,  though  it  may  not  be  possible  to  undo  the  harm 
already  produced  by  the  diphtheria  toxin.  Cases  treated  very  early 
give  the  best  results.  This  is  well  shown  by  the  following  table  of 
the  cases  injected  in  1902-4,  prepared  by  the  New  York  Health 
Department: 


Day. 

No.  cases. 

Case  fatality. 

Percentage. 

I 

623 

10 

1.6 

2 

1689 

53 

31 

3  and  4 

1871 

127 

6.7 

5  and  over 

455 

82 

18 

The  Syringe. — The  simpler  the  syringe,  the  better.     The  syringe 
should  have  a  capacity  of  about  i  1/4  to  2  1/2  drams  (5  to  10  c.c). 


Fig.   163. — The  record  antitoxin  syringe. 

Glass  syringes  with  asbestos  packing  or  those  with  the  solid  glass 
piston,  as  the  Luer,  are  most  easily  sterilized.  The  record  syringe 
(Fig.  163)  is  also  an  excellent  instrument.  A  moderately  fine  needle 
or  the  smallest  through  which  the  serum  will  flow  is  preferable  to  one 


ADMINISTRATION    OF    DIPHTHERIA    ANTITOXIN 


185 


of  very  large  caliber.  In  charging  the  syringe  it  is  better  to  remove 
the  piston  and  pour  the  antitoxin  into  the  syringe,  as  it  is  difficult  to 
draw  it  up  through  the  needle.  The  piston  is  then  inserted  and,  with 
the  syringe  elevated,  any  air  is  expelled.  Many  of  the  manufac- 
turers at  the  present  time  Supply  a  syringe  already  sterilized  and  filled 
with  antitoxin  (Fig.  164).  The  advantages  of  this  in  the  saving  of 
time  are  obvious. 


Fig.  164. — -The  New  York  Board  of  Health  Antitoxin  Syringe.  The  syringe 
comes  steriHzed  and  already  loaded  with  antitoxin  and,  upon  inserting  the  needle 
into  the  distal  end,  is  ready  for  use. 

Site  of  Injection. — The  subcutaneous  tissues  of  the  outer  aspect 
of  the  thigh,  of  the  back  part  of  the  axilla,  or  of  the  upper  portion  of 
the  abdomen  are  usually  chosen  for  the  injection  (Fig.  165). 

Asepsis. — The  syringe  and  needles  should  always  be  sterilized  by 
a  thorough  boiling  before  use.  The  operator's  hands  are  cleansed  as 
for  any  operation,  and  the  skin  at  the  site  of  injection  is  sterilized  by 
painting  with  tincture  of  iodin. 

Technic. — In  order  to  prevent  any  undue  excitement,  the  injec- 
tion should  be  made  with  the  patient  in  such  a  position  that  he  cannot 


Fig.   165. — Sites  for  antitoxin  injection. 

see  what  is  going  on;  in  children  this  Is  especially  necessary.  Care 
must  be  taken  to  expel  any  air  from  the  syringe  by  elevating  its  point 
and  depressing  the  piston  a  little.  A  fold  of  the  skin  from  the  area 
previously  sterilized  is  then  raised  up  between  the  thumb  and  fore- 
finger of  the  left  hand,  and,  with  the  right  hand,  the  needle  is  quickly 
plunged  into  the  subcutaneous  tissue  (Fig.  166).  If  done  quickly 
with  a  sharp-pointed  needle,  preliminary  local  anesthesia  of  the  skin 
is  unnecessary.  The  serum  is  then  injected  very  slowly  and  the  swell- 
ing produced  is  not  massaged,  being  allowed  to  subside  as  the  serum 


i86 


HYPODERMIC    AND    INTRAMUSCULAR   INJECTIONS,    ETC- 


is  absorbed.  After  withdrawal  of  the  needle  the  puncture  is  sealed 
with  collodion  and  cotton.  Following  the  injection  there  may  be  a 
slight  reaction  consisting  of  some  redness,  edema,  and  pain  at  the 
site  of  puncture,  but  these  usually  subside  in  a  short  time. 

Effects  of  Antitoxin. — In  favorable  cases  a  prompt  and  marked 
improvement  in  the  local  and  general  symptoms  follows  the  use  of 
antitoxin.  In  a  few  hours  the  pseudomembrane  begins  to  lose  its 
dirty  color  and  becomes  blanched  and  somewhat  swollen.  Within 
twelve  to  twenty-four  hours  the  membrane  loosens  at  the  edges  and 


Fig.   1 66. — Showing  the  method  of  injecting  diphtheria  antitoxin  in  the  subcuta- 
neous tissue  of  the  axilla. 


rolls  up,  becoming  detached  in  a  mass,  or  in  small  pieces.  This  seems 
to  take  place  more  rapidly  about  the  tonsils  than  elsewhere.  The 
usual  time  for  restoration  to  the  normal  condition  in  the  throat  is 
twenty-four  hours  to  three  or  four  days.  Sometimes  the  membrane, 
after  disappearing,  forms  again;  such  cases  should  promptly  receive 
more  antitoxin. 

In  nasal  diphtheria  similar  effects  are  observed,  each  irrigation 
bringing  away  small  or  large  pieces  of  detached  membrane.  The 
nasal  discharge  and  swelling  soon  diminish,  and  at  the  same  time  the 
mouth  breathing  ceases. 

In  laryngeal  diphtheria  antitoxin  prevents  the  extension  of  the 
membrane  into  the  trachea  and  bronchi  in  the  majority  of  cases,  and 
since  its  introduction  it  has  been  necessary  to  operate  upon  a  much 
smaller  proportion  of  cases  than  formerly. 


ADMINISTRATION    OF    DIPHTHERIA   ANTITOXIN 


187 


The  effects  upon  the  constitutional  symptoms  are  Ukewise  impres- 
sive. In  favorable  cases  the  general  condition  of  the  patient  improves 
noticeably  within  twelve  to  twenty-four  hours.  The  constitutional 
symptoms  of  toxemia  disappear,  the  color  and  general  appearance  are 
altered,  and  the  appetite  begins  to  improve.  The  temperature  may 
rise  I  or  2  degrees  in  the  first  four  or  five  hours  after  the  injection,  and 
the  pulse  may  be  accelerated  at  the  same  time,  but  this  is  followed  in 
favorable  cases  by  a  fall  of  the  fever  either  by  crisis  or  by  lysis  the 
temperature  becoming  practically  normal  in  two  or  three  days.  The 
persistence  of  fever  is  an  indication  for  a  second  dose  of  antitoxin. 


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CASE     FATALITY                                                                    1 

DEATH     RATE.                                                                          | 

Fig.   167. — Chart  prepared  by  the  New  York  Board  of  Health,  showing  the  reduc- 
tion in  the  mortaUty  from  diphtheria  since  the  introduction  of  antitoxin. 


The  reduction  in  the  mortahty  rate  since  the  introduction  of  anti- 
toxin is  well  shown  in  the  following  table  (Fig.  167)  prepared  by  the 
New  York  Department  of  Health,  the  small  reduction  shown  in  the 
first  three  years  of  its  use  being  explained  by  the  fact  that  sufficiently 
large  doses  of  antitoxin  were  not  used  at  first  and  that  the  serum  used 
later  was  more  efficient. 

Complications. — In  a  certain  percentage  of  cases  skin  eruptions 
develop  after  several  days.  These  may  be  erythematous,  scarlati- 
form,  morbiliform,  or  urticarial  in  character.  Urticaria  is  said  to 
follow  in  about  30  per  cent,  of  the  cases  and  usually  comes  on  from  the 
eighth  to  the  fourteenth  day.  It  frequently  develops  upon  the  but- 
tocks, abdomen,  and  chest  and  may  be  the  cause  of  great  discomfort 


1 88  HYPODERMIC    AND    INTRAMUSCULAR    IN'JECTIONS,    ETC. 

and  annoyance  to  the  patient.     Infection  and  cellulitis  may  result 
from  the  injection  if  due  regard  to  asepsis  is  not  observed. 

Painful  conditions  in  the  large  joints,  as  the  hips,  knees,  wrists, 
and  shoulders,  occur  in  a  small  proportion  of  the  cases.  These  symp- 
toms, however,  are  not  due  to  the  antitoxin,  but  are  caused  by  the 
horse  serum,  and  depend  upon  the  susceptibility  of  the  patient  to  the 
serum. 

VACCINATION 

Vaccination  is  the  inoculation  with  the  vaccine  or  virus  of  cowpox 
for  the  purpose  of  inducing  that  disease  in  man  and  thereby  affording 
partial  or  permanent  protection  against  smallpox. 

The  immunity  rendered  by  vaccination  is  not  claimed  to  be  invari- 
ably complete.  In  a  great  majority  of  cases,  though,  a  successful 
inoculation  grants  a  person  immunity  to  smallpox  for  a  number  of 
years,  though  the  effects  may  in  time  wear  off  and  the  individual  again 
become  susceptible.  The  mortality  in  such  cases,  however,  is  very 
low  compared  with  the  mortality  in  those  who  have  never  been  vac- 
cinated. According  to  Osier,  in  the  former  it  is  6  to  8  per  cent,  and  in 
the  unvaccinated  not  less  than  35  per  cent. 

The  nature  of  the  protection  thus  afforded  is  not  absolutely  under- 
stood, but  the  results  of  vaccination  are  unquestionable  and  admir- 
ably attest  its  efiEiciency.  Localities  in  which  vaccination  is  systemat- 
ically carried  out  develop  fewer  cases  and  present  the  lowest  death 
rate  from  smallpox.  In  Germany,  since  1874,  compulsory  vaccina- 
tion and  revaccination  have  been  enforced  and  since  then  there  have 
been  no  epidemics  of  smallpox  in  that  country.  On  the  other  hand, 
the  results  of  disregard  to  the  value  of  vaccination  are  well  illustrated 
by  the  mortality  rate  of  smallpox  in  European  countries  between 
1893  and  1897,  inclusive,  quoted  by  Schamberg  {New  York  Medical 
Journal,  Jan.  16,  1909)  from  the  Imperial  Board  of  Health  reports  of 
the  German  Empire.  He  says:  "We  are  startled  to  note  in  this  per- 
iod there  died  in  the  Russian  Empire,  including  Asiatic  Russia,  275,- 
502  persons  from  smallpox,  Spain  lost  over  23,000  lives,  Hungary  over 
12,000,  Austria  and  Italy  over  11,000.  In  Germany  the  number  of 
smallpox  deaths  during  this  period  was  only  287,  representing  one 
death  to  every  1,000,000  of  population  a  year." 

The  Virus. — The  virus  should  always  be  obtained  from  a  reliable 
source.  That  from  the  calf  is  to  be  used  by  preference.  Humanized 
lymph  should  never  be  employed  except  upon  imperative  occasions 
when  bovine  lymph  is  not  procurable. 


VACCIXATIOX 


189 


The  virus  is  obtained  under  rigid  aseptic  precautions  by  cujetting 
the  pustule  from  a  calf  and  making  an  emulsion  of  it  with  glycerin. 
This  is  then  collected  in  capillary  tubes  and  is  hermetically  sealed 
imtil  used.  The  lymph  should  not  be  distributed  until  it  has  been 
tested  for  tetanus  and  other  pathogenic  germs,  and  an  autopsy  has 
been  performed  upon  the  calf  to  make  certain  it  was  free  from  disease. 
The  lymph  may  also  be  obtained  spread  upon  ivory  or  celluloid  points, 
but  they  are  not  preferable  to  the  capiUary  tubes  as  there  is  danger  of 
the  virus  being  contaminated  by  handling. 

Time  for  Vaccination. — In  choosing  the  time  for  vaccination  the 
age  and  the  general  health  of  the  individual  should  be  taken  into 
consideration.  As  a  general  rule,  unless  contraindicated,  the  child 
should  be  three  to  sLx  months  old  before  vaccination.  The  operation 
should  be  avoided  if  possible  in  dentition;  and  children  who  are 
delicate  or  suffering  from  malnutrition,  syphihs,  or  skin  eruptions, 
should  not  be  vaccinated  until  in  good  condition.  The  best  season  is 
in  the  early  fall  or  spring  when  there  is  less  danger  of  epidemics  of 
contagious  diseases,  such  as  scarlet  fever,  measles,  diphtheria, 
whooping-cough,  etc.  Upon  exposure  to  smallpox,  whether  the  indi- 
vidual is  in  infancy  or  in  old  age.  he  should  always  be  immediately 
vaccinated. 

Instruments. — A  sharp-pointed  scalpel  or  a  lancet  is  as  useful  an 
instrument  as  can  be  found  for  performing  the  scarification.     Sharp 


5  ^ 


Fig.  168. — Xew  York  Department  of  Health  vaccination  outfit,  i,  Instru- 
ments in  case;  2,  rubber  tube  for  blowing  the  virus  out  of  the  tube;  3,  tube  con- 
taining virus;  4,  needle  for  scarification;  5,  stick  for  spreading  the  virus. 


needles  may  also  be  employed  and.  as  they  are  cheap,  the  same 
needle  need  not  be  used  for  more  than  one  case.  Special  scarificators 
are  made,  but  they  have  no  advantages  over  a  lancet  or  a  needle.  If 
the  vaccine  points  are  used,  no  scarificator  is  necessary. 

The  Xew  York  Department  of  Health  supplies  with  each  capillary 
tube  of  vaccine  virus,  a  needle,  a  flat  tooth  pick  for  spreading  the  virus. 


igo 


HYPODERMIC    AND    INTRAMUSCULAR    INJECTIONS,    ETC. 


and  a  piece  of  small  rubber  tubing  which  fits  over  one  end  of  the  cap- 
illary tube  and  is  used  to  blow  the  vaccine  out  of  the  tube  (Fig.  i68). 
Site  of  Vaccination. — The  vaccination  is  performed  either  upon 
the  arm  or  leg.  As  a  rule,  the  arm  is  preferred  as  a  site,  especially  in 
children  who  are  running  about,  as  being  more  easily  kept  at  rest  and 
less  likely  to  be  injured.  Mothers  often  prefer  to  have  their  girls 
vaccinated  upon  the  leg  to  avoid  the  disfiguring  eiifect  of  the  scar. 
If  the  arm  is  chosen,  the  point  selected  is  at  about  the  insertion  of  the 
deltoid  muscle;  in  the  leg  a  spot  on  the  outer  aspect  at  the  junction 
of  the  middle  and  upper  third  is  selected. 


Fig.    169. — Vaccination.     First  step,  scarifying  the  arm. 

Asepsisi — The  operation  of  vaccination  should  be  regarded  as  an 
important  one  and,  as  most  of  its  dangers  are  due  to  infection,  the 
operator  should  see  that  all  aseptic  precautions  are  observed.  The 
instrument  employed  for  scarifying  the  skin  should  be  carefully  ster- 
ilized and  the  same  instrument  should  not  be  used  more  than  once 
without  resterilization.  The  hands  of  the  operator  are  prepared  as 
carefully  as  for  any  operation.  The  patient's  skin  is  washed  with 
soap  and  warm  water  followed  by  alcohol  and  ether  and  is  allowed  to 
dry.  The  use  of  strong  disinfectants  is  not  advised  as  the  chances  of  a 
successful  inoculation  may  be  lessened. 

Technic. — Vaccination  by  the  scarification  method  is  generally 
practised  in  this  country.  A  proper  spot  is  chosen  upon  the  arm  or 
leg.  and  an  area  1/8  to  1/4  inch  (3  to  6  mm.)  in  diameter  is  scarified 
by  making  a  number  of  scratches  at  right  angles  to  each  other  in 
the  skin  with  the  point  of  the  instrument  just  deep  enough  to  draw 


VACCINATION 


191 


serum,  but  no  blood  (Fig.  169).     If  more  than  one  inoculation  is  to  be 
made,  as  is  frequently  done,  the  area  scarified  should  be  at  a  distance 


Fig.   170. — Vaccination.     Second  step,  blowing  the  virus  out  of  the  capillary  tube 
onto  a  small  piece  of  wood. 


Fig.   171. — Vaccination.     Third  step.     Rubbing  the  virus  into  the  scarified  area. 

of  at  least  i  inch  (2.5  cm.)  apart.  The  virus  is  then  deposited  upon 
the  scarified  area,  being  rubbed  in  with  some  sterile  instrument  for  a 
full  minute  and  allowed  to  dry  (Fig.  171).     The  site  of  vaccination  is 


192 


HYPODERMIC    AND    INTRAMUSCULAR    INJECTIONS,    ETC. 


finally  covered  with  a  piece  of  sterile  gauze  held  in  place  with  two 
small  strips  of  adhesive  plaster,  or,  if  desired,  a  wire  shield  (Fig.  172) 
may  be  used,  provided  it  is  applied  in  such  a  way  as  not  to  constrict 
the  arm  (Fig.  173).  After  the  vesicle  has  formed,  the  part  should  be 
gently  washed  with  sterile  water  once  a  day  and  dressed  with  fresh 
gauze  or  covered  with  a  shield  to  prevent  contact  with  the  clothing. 

Course  of  Vaccination. — Outside  of  a  little  irritation  and  redness 
at  the  site  of  inoculation  there  are  no  immediate  developments  and  the 
wound  heals.  On  the  third  day  a  papule  appears  surrounded  by  an 
area  of  slight  redness.  This  is  followed  in  twenty-four  hours  by  the 
formation  of  a  small  vesicle  which  by  the  seventh  or  eighth  day 
reaches  its  full  development.  It  is  usually  round,  1/4  to  1/2  inch 
(6  to  12  mm.)  in  diameter,  and  full  of  limpid  fluid.     The  center  of  the 


Fig.   172. — Vaccination  shield. 


Fig.   173. — Showing  the  shield  in  place. 


vesicle  is  depressed,  while  the  margins  are  elevated  and  shghtly  indur- 
ated. By  the  tenth  day  a  bright  red  areola  has  developed  covering  a 
space  of  from  i  to  2  inches  (2.5  to  5  cm.)  around  the  vesicle  and  the 
contents  of  the  vesicle  become  purulent.  In  a  day  or  two  more  the 
areola  commences  to  fade  and  the  vesicle  dries  up  forming  a  dark 
brown  crust.  Usually  about  the  twenty-first  day  this  crust  falls  off, 
leaving  a  bluish  pitted  scar  which  later  slowly  fades  to  white. 

Constitutional  symptoms  more  or  less  marked  accompany  the 
eruption.  Remittent  fever  of  from  101°  to  104°  begins  on  the  fourth 
day  and  may  persist  imtil  the  eighth  or  ninth  day.  when  it  drops 
gradually  to  normal.  In  children  irritabihty,  loss  of  appetite,  and 
restlessness  at  night  may  accompany  the  fever.     The  axillary  or 


VACCINATION  1 93 

inguinal  glands  become  swollen  and  sore,  depending  upon  whether 
the  arm  or  leg  is  the  seat  of  inoculation. 

Certain  irregular  types  of  vaccination  are  sometimes  met  with. 
In  rare  cases  a  generalized  vaccine  eruption  with  marked  fever  and 
other  severe  symptoms  may  occur.  Single  vesicles  may  also  be  pro- 
duced on  other  parts  of  the  body  distant  from  the  site  of  inoculation 
by  autoinoculation  from  scratching.  Sometimes  the  period  of  incu- 
bation is  prolonged  and  the  vesicle  formation  is  delayed. 

Complications. — Urticaria,  impetigo  contagiosa,  and  rashes  re- 
sembling those  of  scarlet  fever  or  measles  have  been  observed. 
Erysipelas  may  occur  at  any  time  before  the  sore  heals. 

Suppuration  and  abscess  of  the  axillary  or  inguinal  glands  some- 
times follow  vaccination.  In  anemic  and  unhealthy  subjects,  if 
infection  occurs,  cellulitis  and  deep  ulcers  may  form,  followed  by 
extensive  loss  of  tissue  and  large  scars. 

SyphiHs  is  no  longer  feared  under  modern  methods  of  vaccination ; 
the  same  is  true  of  tuberculosis,  and  it  has  been  shown  in  addition 
that  the  tubercle  bacillus  is  destroyed  in  glycerinated  lymph.  Tet- 
anus can  only  follow  carelessness  as  to  asepsis  and  neglect  of  pre- 
cautions in  preparing  the  lymph. 

Revaccination. — Immunity  furnished  by  vaccination  is  not  per- 
manent, and  in  all  persons  revaccination  should  be  performed  several 
years  after  the  first  vaccination.  The  New  York  Health  Department 
advises  that  revaccination  be  repeated  at  intervals  of  not  more  than 
three  years  if  permanent  immunity  is  to  be  acquired.  .  The  vaccina- 
tion should  be  as  thoroughly  carried  out  as  in  the  first  instance.  In 
cases  of  exposure  to  contagion  during  the  interval,  revaccination 
should  be  performed  at  once. 


CHAPTER  VIII 

TREATMENT  OF  NEURALGIA  BY  INJECTIONS 
TIC  DOULOUREUX 

For  the  purpose  of  relieving  the  pain  of  trifacial  neuralgia  various 
drugs  and  gases,  such  as  stovain,  cocain,  chloroform,  antipyrin,  osmic 
acid,  and  air,  have  been  injected  into  the  branches  of  the  fifth  nerve 
or  subcutaneously  into  the  painful  areas.  Schlosser  in  1900  was  the 
first  to  practise  direct  injection  of  the  different  branches  of  the 
fifth  nerve  with  80  per  cent,  alcohol  at  their  exit  from  the  skull  through 
the  basal  foramina.  Schlosser's  method  of  injection  was,  however, 
rather  difficult,  and  it  was  not  until  Levy  and  Baudouin  in  1906 
devised  a  comparatively  simple  technic  that  alcoholic  injections  were 
employed  to  any  great  extent.  While  injection  of  the  superficial 
branches  of  the  fifth  nerve  with  osmic  acid  and  the  deep  branches  with 
alcohol  have  both  given  brilliant  results,  the  use  of  osmic  acid  neces- 
sitates exposure  of  the  affected  nerve  or  nerves  and,  for  this  reason, 
it  has  been  largely  discarded  in  favor  of  alcohol  alone  or  in  combina- 
tion with  other  drugs. 

Alcohol  when  injected  into  a  nerve  causes  a  degeneration  of  its 
fibers.  Relief  from  pain  is  thus  obtained  usually  for  a  period  of  six 
months  to  two  years,  but  it  varies  considerably  depending  upon  the 
thoroughness  with  which  the  nerve  is  injected.  In  some  cases  one 
injection  has  given  an  apparent  cure,  bat,  as  a  rule,  the  injection 
has  to  be  repeated  several  times. 

All  three  branches  of  the  nerve  have  been  injected,^  but,  on 
account  of  the  difficulty  of  reaching  the  ophthalmic  branch  and  the 
proximity  of  the  optic  nerve,  and  the  third,  fourth,  and  sixth  nerves, 
deep  injection  of  this  branch  has  been  abandoned  by  the  majority  of 
operators . 

Anatomy. — The  fifth  nerve  closely  resembles  a  typical  spinal 
nerve,  being  a  mixed  nerve  with  its  sensory  and  motor  roots  arising 
separately  from  the  brain,  and  the  sensory  root  possessing  a  ganglion, 
the  Gasserian  ganglion.  The  latter  is  a  crescent-shaped  body,  com- 
posed of  nerve  fibers  and  nerve  cells,  lying  in  a  depression,  Meckel's 
cave,  on  the  apex  of  the  petrous  portion  of  the  temporal  bone.     From 

'  More  recently  injections  have  been  made  directly  into  the  Gasserian  ganglion. 

194 


TIC    DOULOUREUX 


195 


the  anterior  convex  border  of  the  ganglion  the  sensory  portion  emerges 
in  three  trunks:  the  ophthalmic,  the  superior  maxillary,  and  the 
inferior  maxillary.  The  superior  maxillary  division  is  joined  on  the 
distal  side  of  the  ganglion  by  the  motor  root. 

The  first  division  passes  from  the  skull  through  the  sphenoidal  fis- 
sure in  three  branches:  the  lachrymal,  the  frontal,  and  the  nasal.  It 
is  purely  a  sensor}-  nerve  supplying  the  upper  eyelid,  conjunctiva, 
eyeball,  lachrymal  gland,  forehead,  anterior  portion  of  the  scalp, 
frontal  sinus,  and  the  root  and  anterior  portion  of  the  nose. 

The  second  division  leaves  the  skull  through  the  foramen  rotundum, 
crosses  the  spheno-maxillary  fossa,  and,  after  entering  the  orbital 


Fig.   174. — Anatomy  of  the  trifacial  ner\^e.     (After  Campbell.) 


cavity  through  the  spheno-maxillary  fissure,  passes  to  the  face  by  way 
of  the  infraorbital  groove.  It  is  also  a  sensory  nerve,  supplying  the 
cheek,  anterior  portion  of  the  temporal  region,  the  lower  eyehd,  the 
ridge  of  the  nose,  upper  lip.  upper  teeth,  mucous  membrane  of  the 
nose,  nasopharynx,  antrum,  posterior  ethmoidal  cells,  soft  palate, 
tonsil,  and  roof  of  the  mouth. 

The  third  division  is  a  mixed  nerveformedby  the  third  trunk  of  the 
sensory  root  and  the  motor  root.  The  two  pass  from  the  cranium 
through  the  foramen  ovale  and  immediately  unite  to  form  a  single 
branch.  The  sensory  portion  of  the  nerve  supplies  the  skin  of  the 
side  of  the  head,  auricle  of  the  ear,  external  auditory  meatus,  lower 
portion  of  the  face,  lower  lip,  lower  teeth  and  gums,  mucous  mem- 


196 


TREATMENT   OF   NEURALGIA  BY   INJECTIONS 


brane  of  the  mouth,  tongue,  and  mastoid  cells,  and  salivary  glands. 
The  motor  portion  supplies  the  muscles  of  mastication. 

Instruments. — There  will  be  required  a  special  needle  4  3/4  inches 
(12  cm.)  long  and  1/14  in.  (1.75  mm.)  in  diameter,  a  glass  syringe 
with  a  capacity  of  at  least  30  minims  (2  c.c),  a  scalpel,  a  fine  needle, 
2  1/2  inches  (5  cm.)  long  which  can  be  fitted  to  the  syringe  for  the 
purpose  of  infiltrating  the  skin  at  the  site  of  puncture  or  performing 
peripheral  injections  of  nerve  branches,  and  two  medicine  glasses, 
one  for  a  cocain  solution  and  the  other  for  the  alcohol  solution 
(Fig.  175)- 


Fig.  175. — Apparatus  for  injecting  the  branches  of  the  fifth  nerve,  i,  Two 
medicine  glasses;  2,  Luer  syringe;  3,  Levy  and  Baudouin  needle;  4,  small  hypo- 
dermic needle;  5,  ampoule  containing  anesthetic;  6,  scalpel. 

The  needle  should  have  rather  a  blunt  point  and  should  be  pro- 
vided with  a  stylet  which  extends  flush  with  the  point  of  the  needle 
when  pushed  home.  The  outside  of  the  needle  is  graduated  in  cen- 
timeters up  to  five.  The  proximal  end  of  the  needle  should  be  made 
to  accurately  fit  the  end  of  the  syringe  (Fig.  176). 


Fig.    176.— Enlarged  view  of  the  Levy  and  Baudouin  needle  and  stylet. 

Solution  Used. — The  solution  originally  used  was  a  mixture  of 
cocain,  morphin,  chloroform,  and  80  per  cent,  alcohol,  but  the  mor- 
phin  and  chloroform  are  generally  discarded  at  the  present  time.  The 
addition  of  chloroform  causes  considerable  inflammation  at  the 
site  of  injection  and  the  formation  of  scar  tissue.     Patrick  {Jour- 


nal of  the  Americaji  Medical  Association, 
following: 


Jan.  20,    1912'!   uses   the 


Cocain  muriat.,  gr.  ii  (0.13  gm.) 

Alcohol,  dr.  iiiss  (13  c.c.) 

Aq.  dest.,  q.s.  ad.,  oz.  ss  (15  c.c.) 

The  solution  should  be  freshly  prepared  for  each  injection. 


TIC   DOULOUREUX 


197 


Quantity  Used. — For  a  deep  injection  3oTn.  (2  c.c.)  of  solu- 
tion are  generally  injected  into  each  branch.  Eight  minims  (0.5 
c.c.)  is  sufficient  for  a  peripheral  injection. 

Position  of  Patient. — The  injection  is  made  with  the  patient  sit- 
ting upright  in  a  chair  or  the  recumbent  position  may  be  employed 
with  the  patient's  head  resting  on  the  side. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  the  operator's 
hands  cleansed  as  for  any  operation,  and  the  site  of  injection  painted 
with  tincture  of  iodin. 

Anesthesia. — General  anesthesia  is  to  be  avoided  if  possible,  as 
the  best  guide  to  a  successful  injection  is  the  spasm  of  pain  and  the 


Fig.   177. — Showing  the  method  of  injecting  the  supraorbital  branch  of  the  first 
division  of  the  fifth  nerve. 


anesthesia  that  results  over  the  area  of  distribution  of  the  nerve. 
Infiltration  of  the  skin  with  a  few  drops  of  0.2  per  cent,  cocain  solu- 
tion or  a  I  per  cent,  novocain  solution  at  the  point  through  which 
the  needle  enters  is  usually  sufficient. 

Technic. — The  site  of  injection  and  the  direction  in  which  the 
needle  islnserted  will  vary  according  to  the  branch  injected. 

First  Division. — Deep  injection  of  this  nerve  at  the  sphenoidal  fis- 
sure is  rarely  practised  on  account  of  its  dangers;  instead,  the  supra- 
orbital nerve  is  injected  at  the  supraorbital  notch  or  foramen.  The 
supraorbital  notch  is  located  by  palpation  or  by  the  sensations  of 
the  patient  when  the  nerve  is  compressed  between  the  finger  and  the 
skull.  The  skin  over  the  site  of  the  notch  is  anesthetized,  and  an 
attempt  Is  made  to  insert  the  fine  needle  into  the  foramen,  the  eye- 
ball being  protected  by  the  index  finger  of  the  operator's  left  hand 


198 


TREATMENT    OF   NEURALGIA   BY    INJECTIONS 


(Fig.  177).  When  the  needle  strikes  the  nerve  a  sharp  shooting  pain 
will  be  felt  by  the  patient  extending  up  the  forehead.  If  possible, 
the  needle  should  be  inserted  for  a  distance  of  1/5  to  2/5  of  an  inch 
(5  to  10  mm.)  into  the  canal.  About  10  minims  (0.6  c.c.)  of  the 
alcohol  solution  is  then  injected.  A  successful  injection  will  result  in 
immediate  anesthesia  within  the  distribution  of  the  nerve. 

The  Second  Division  is  injected  at  the  foramen  rotundum.  The 
posterior  border  of  the  orbital  process  of  the  malar  bone  is  identified 
and  from  it  is  dropped  a  verticle  line  to  the  lower  border  of  the  zy- 
goma; 1/5  inch  (0.5  cm.)  behind  the  point  where  this  perpendicular 
line  crosses  the  zygoma  is  the  point  for  entrance  of  the  needle.     The 


Fig.   178. — -Needle  in  place  for  injecting  the  second  division  of  the  fifth  nerve. 

skin  at  this  point  is  infiltrated  with  cocain  and  is  nicked  with  a 
scalpel.  The  needle  is  inserted  with  the  stylet  withdrawn  until  it  is 
well  into  the  subcutaneous  tissues;  then  the  stylet  is  pushed  home  in 
order  to  furnish  a  blunt  point  and  avoid  any  injury  to  the  blood- 
vessels. The  direction  of  the  needle  should  be  at  first  horizontally 
inward  and  then  slightly  upward,  and  at  a  depth  of  2  inches  (5  cm.) 
the  needle  should  reach  the  nerve  at  the  foramen  rotundum.  If, 
after  passing  through  the  subcutaneous  tissue,  the  needle  strike  the 
coronoid  process  of  the  lower  jaw,  it  will  have  to  be  re-inserted  at  a 
point  shghtly  more  forward.  This  will  necessitate  changing  the 
angle  of  the  needle  to  correspond  with  the  new  site  of  entrance.  Care 
must  be  observed  against  inserting  the  needle  so  far  forward  that  the 
orbit  will  be  entered  or  so  deep  that  the  sixth  nerve  is  reached.  With 
the  needle  introduced  the  correct  distance,  the  stylet  is  withdrawn 


TIC   DOULOUREUX 


199 


and  the  alcohol  solution  is  slowly  injected  and,  if  the  needle  is  prop- 
erly placed,  a  sharp  pain  will  be  felt  by  the  patient  in  the  area  of 
distribution  of  the  nerve.  If  the  nerve  is  not  reached,  the  needle 
should  be  withdrawn  a  little  and  its  direction  shghtly  changed.  At 
the  completion  of  the  injection,  the  needle  is  removed  and  the  point 
of  puncture  is  sealed  with  collodion  and  cotton.  The  patient  should 
be  kept  in  a  recumbent  position  for  10  to  15  minutes. 

If  it  is  found  impossible  to  reach  the  nerve  at  its  exit  from  the 
skull,  its  infraorbital  branch  may  be  injected  at  the  infraorbital 
foramen,  using  a  long  fine  needle  for  this  purpose.  About  10  to  15 
minims  (0.6  to  i  c.c.)  of  the  solution  are  injected. 

The  Third  Division  is  injected  at  the  foramen  ovale.  The  descend- 
ing root  of  the  zygoma  is  identified,  and  at  a  point  I  inch  (2.5  cm.) 
in  front  of  it  just  below  the  zygoma,  the  needle  enters  the  skin.  The 
skin  at  this  point  is  anesthetized  and  is  nicked  with  a  scalpel,  and  the 
needle  with  the  stylet  withdrawn  is  pushed  through  the  subcutaneous 


Fig.   179.-— Needle  in  place  for  injecting  the  third  division   of  the  fifth  nerve. 


tissues  in  a  direction  slightly  upward  and  backward.  The  stylet  is 
then  pushed  home,  and  needle  is  carried  in  through  the  deeper  tis- 
sues, still  slightly  upward  and  backward,  until  it  reaches  a  depth  of 
1 1/2  inches  (4  cm.);  it  should  then  be  at  the  foramen  ovale.  When  the 
needle  strikes  the  nerve,  the  patient,  as  a  rule,  will  be  conscious  of  a 
sharp  pain  in  the  tongue  or  lower  jaw.  The  stylet  is  then  removed, 
the  syringe,  loaded  with  the  alcohol  solution,  is  fitted  to  the  needle, 
and  the  injection  is  made.  At  the  completion  of  the  operation,  the 
needle  is  withdrawn  and  the  skin  puncture  is  sealed  with  collodion 
and  cotton. 


200 


TREATMENT    OF    NEURALGIA  BY    INJECTIONS 


Following  a  deep  injection,  there  is  considerable  swelling  of  the 
face,  which  the  patient  should  be  warned  beforehand  to  expect. 
Sometimes  a  hematoma  may  result  from  puncture  of  some  vessel 
during  the  insertion  of  the  needle.  To  avoid  this,  Patrick  advises 
that  the  needle  always  be  inspected  for  oozing  and,  if  present, 
that  the  needle  and  stylet  be  left  in  place  until  it  stops. 

SCIATICA 

The  injection  of  alcohol  and  other  drugs  which  have  a  destructive 
action  upon  nerves  and  which  have  been  effectively  employed  in 
neuralgia  of  the  fifth  nerve  should  be  avoided  in  sciatica,  as  the  sciatic 
is  a  mLxed  nerve  and  the  use  of  such  drugs  has  produced  grave  motor 
changes- in  the  nerve.     The  injection  of  physiological  salt  solution, 


Fig.  i8o. — Apparatus  for  injecting  the  sciatic  nerve.  I,  Medicine  glass;  2, 
glass  graduate;  3,  large  glass  syringe  and  blunt  needle  for  injecting  the  nerve;  4, 
ampoule  of  cocain;  5,  small  syringe  and  needle  for  the  preliminary  infiltration  of 
the  site  of  puncture;  6,  scalpel. 

however,  has  given  good  results  in  relieving  the  pain  of  sciatica  with- 
out causing  any  harmful  results.  The  injection  is  made  into  the 
nerve-sheath  with  the  idea  of  separating  the  adhesions  that  have 
formed  around  the  inflamed  nerve,  and,  if  it  is  used  in  the  proper 
cases,  in  the  great  majority  of  instances  it  gives  rehef.  Frequently 
more  than  one,  and  in  the  severe  cases,  a  number  of  injections  are 
required  to  produce  a  cure. 

Apparatus. — There  will  be  required  a  needle  43/4  inches  (12 
cm.)  long  and  1/16  inch  (1.5  mm.)  in  diameter,  a  glass  syringe  with 
a  capacity  of  3  to  4  ounces  (90  to  120  c.c),  a  piece  of  rubber  tubing  to 
connect  the  syringe  and  needle,  a  scalpel,  a  cocain  syringe,  a  small 
medicine  glass  for  the  cocain  solution,  and  a  glass  graduate  for  the 
salt  solution  (Fig.  180). 


SCIATICA 


20I 


The  needle  is  of  a  type  similar  to  that  used  for  trifacial  injections 
(see  Fig.  176).  It  should  be  graduated  in  centimeters  from  i  to  10, 
and  the  point  should  be  rather  blunt. 

Solution  Used. — ^Normal  salt  solution  (salt  i  dram  (4  gm.)  to  a 
pint  (500  c.c.)  of  boiled  water)  with  or  without  the  addition  of  a  local 
anesthetic  is  used. 

Temperature  of  the  Solution. — The  solution  is  injected  either  at 
about  the  temperature  of  the  body  or  at  32°  F.  (0°  C). 

Quantity. — Two  to  4  ounces  (60  to  120  c.c.)  of  the  warm  solution 
and  2  1/2  to  5  drams  (10  to  20  c.c.)  of  the  cold  solution  may  be 
injected. 

Intervals  between  Injections. — When  it  is  necessary  to  repeat 
the  injections,  they  may  be  given  at  intervals  of  24  to  72  hours. 

Site  of  Injection. — Several  points  for  reaching  the  nerve  are 
advised.     That  used  by  D'Orsay  Hoecht  and  one  that  gives  access  to 


Fig.   181. — Showing  the  method   of  locating  the  point  for  injecting  the  sciatic 

nerve.     (After  Hoecht.) 


the  nerve  high  up  is  as  follows:  A  line  is  drawn  from  the  sacrococ- 
cygeal joint  to  the  postero-external  border  of  the  great  trochanter, 
and  one  finger's  breadth  external  to  the  junction  of  the  inner  one-third 
and  outer  two-third  of  this  line  is  the  point  for  inserting  the  needle 
(Fig.  181). 

The  nerve  may  also  be  reached  by  inserting  the  needle  at  a  point 
where  a  horizontal  line  through  the  tip  of  the  great  trochanter  cuts  a 
verticle  line  through  the  outer  margin  of  the  tuberosity  of  the  ischium. 

Position  of  the  Patient.^ — The  patient  lies  upon  the  abdomen  with 
the  legs  extended  and  with  a  pillow  beneath  the  groins. 


202  TREATMENT    OF    NEURALGIA   BY    INJECTIONS 

Asepsis. — The  instruments  are  boiled,  the  hands  of  the  operator 
are  sterilized  as  carefully  as  for  any  operation,  and  the  field  of  opera- 
tion is  painted  with  tincture  of  iodin. 

Anesthesia. — The  point  on  the  skin  through  which  the  needle  is 
inserted  is  anesthetized  by  infiltration  with  a  few  drops  of  a  0.2 
per  cent,  solution  of  cocain  or  a  i  per  cent,  solution  of  novocain. 

Technic. — The  syringe  is  filled  with  the  salt  solution  of  the  proper 
temperature  and  is  placed  ready  for  use  near  at  hand.  A  small  nick 
is  made  in  the  skin  at  the  point  chosen  for  the  puncture,  and  the 
needle,  armed  with  the  stylet,  is  inserted  perpendicularly  to  the  body 
through  the  tissues  until  it  hits  the  nerve.  If  the  needle  strikes  bone, 
it  is  then  withdrawn  1/25  inch  (i  mm.)  and  should  be  in  close  prox- 
imity to  the  nerve.  The  moment  the  nerve  is  reached  the  patient 
experiences  a  sharp  lancinating  pain  low  down  the  back  of  the  leg  or 
in  the  heel,  frequently  accompanied  by  a  jerking  motion  of  the  leg. 
The  stylet  is  then  removed,  the  syringe  is  attached  to  the  needle,  and 
the  desired  amount  of  solution  is  slowly  and  steadily  injected.  At 
the  end  of  the  injection,  the  needle  is  removed,  and  the  site  of  skin 
puncture  is  sealed  with  collodion  and  cotton. 

Following  the  injection,  the  patient  should  be  instructed  to  keep 
quiet  for  several  days.  For  the  first  few  days  there  may  be  some  sore- 
ness, and  not  infrequently  there  is  a  slight  rise  of  temperature  for  the 
first  24  to  48  hours. 


CHAPTER  IX 

BIER'S  HYPEREMIC  TREATMENT  AND  THE  DIAGNOSIS 

AND  TREATMENT  OF  FISTULOUS  TRACTS  BY 

MEANS  OF  BISMUTH  PASTE 

HYPEREMIC  TREATMENT 

While  the  value  of  artificially  producing  hyperemia  with  the 
definite  purpose  of  increasing  the  inflammatory  reaction  has  only 
recently  been  recognized,  it  is  interesting  to  note  that  as  early  as  the 
sixteenth  century  Ambroise  Pare  employed  artificial  congestion  in 
delayed  union  of  fracture  due  to  insufficient  callus  formation.  Others 
later  and  independently  have  called  attention  to  the  value  of  hypere- 
mia in  similar  conditions.  To  Bier,  however,  belongs  the  credit  of 
placing  treatment  by  hyperemia  upon  a  logical  and  scientific  basis, 
and  of  demonstrating  its  great  practical  value. 

There  are  two  distinct  forms  of  hyperemia,  namely,  active  and 
passive.  The  former,  obtained  by  means  of  dry  hot  air,  produces  a 
more  active  flow  of  arterial  blood  through  the  parts,  and  is  especially 
useful  for  the  absorption  of  the  products  of  chronic,  nontubercular 
inflammations.  The  passive,  venous,  or  obstructive  form  of  hypere- 
mia, as  it  is  designated,  has  for  its  object  the  increase  of  the  amount 
of  venous  blood  in  the  part,  and  may  be  produced  by  means  of  elastic 
compression  of  the  venous  circulation,  or  by  suction  cups.  This 
form  gives  the  best  results  in  pyogenic  infections,  whether  acute  or 
chronic. 

PASSIVE  HYPEREMIA 

Bier  was  first  led  to  employ  passive  hyperemia  through  study  of 
the  observations  of  Farre  and  Travers  who,  as  far  back  as  1815, 
called  attention  to  the  frequency  of  phthisis  in  persons  whose  lungs 
were  rendered  anemic  because  of  stenosis  of  the  pulmonary  orifice, 
and  by  the  reverse  of  this,  namely,  the  rarity  of  pulmonary  tubercu- 
losis in  individuals  suffering  from  cardiac  conditions  tending  to  pro- 
duce congestion  or  hyperemia  of  the  lungs,  as  later  pointed  out  by 
Rokitansky.  Impressed  by  these  observations,  Bier  conceived  the 
idea  of  artificially  producing  a  hyperemia  for  the  cure  of  tubercular 
affections  in  other  parts  of  the  body.     Encouraged  by  the  results 

203 


204  BIER  S    HYPEREMIC    TREATMENT 

-  obtained  in  the  treatment  of  tubercular  affections,  he  soon  extended 
the  use  of  hyperemia  to  the  treatment  of  acute  inflammatory  surgical 
conditions,  with  most  remarkable  results.  In  this  he  was  materially 
aided  by  his  associate,  Klapp,  who  broadened  the  scope  of  the  method 
by  devising  variously  shaped  glass  cups  and  vacuum  apparatus  for 
producing  a  hyperemia  of  regions  of  the  body  not  amenable  to  the 
constricting  band,  though  it  is  true  Bier  had  himself  employed  this 
method  previously  and  had  abandoned  it. 

Treatment  by  hyperemia  is  based  on  the  theory  that  inflamma- 
tion represents  nature's  efforts  for  protection  of  the  body  against 
bacterial  invasion  and  in  the  restoration  of  a  part  to  a  healthy  condi- 
tion. Bier's  teachings  in  regard  to  inflammation  take  exactly  the 
opposite  view  from  what  has  hitherto  been  held  and  taught.  For- 
merly it  was  the  aim  of  treatment  to  combat  in  every  way  possible 
the  phenomena  accompanying  an  inflammation.  In  the  presence  of 
pain,  heat,  redness,  and  swelling,  cold  applications,  elevation  of  the 
part,  rest,  and  immobilization  were  advocated  for  the  rehef  of  these 
symptoms.  According  to  Bier,  however,  the  redness,  heat,  and 
swelling  of  an  inflammation  are  but  the  outward  signs  of  the  effort  on 
the  part  of  nature  to  overcome  noxious  influences  and  produce  a  cure; 
and  these  are  to  be  encouraged  as  beneficial  instead  of  combated.  An 
attempt  was  accordingly  made  to  artificially  reproduce  the  most 
evident  of  these  phenomena,  namely,  congestion  or  hyperemia,  and 
thereby  increase  the  natural  resistance  of  the  tissues. 

Difficult  as  it  may  be  to  give  up  our  old  ideas  and  accept  a 
method  of  treatment  so  radically  at  variance  with  former  teachings, 
the  results  obtained  under  hyperemia,  properly  carried  out,  are  in 
certain  cases  so  remarkable  and  so  far  in  advance  of  any  other 
methods  as  to  furnish  ample  evidence  of  its  superior  value  and  to 
prove  conclusively  the  correctness  of  the  theories  upon  which  Bier's 
treatment  rests. 

Effects  of  Hyperemia. — The  beneficial  effects  of  hyperemia  are 
most  striking — the  more  marked,  the  earlier  the  treatment  is  begun. 

Diminution  of  Pain. — The  prompt  relief  of  pain  is  one  of  the  most 
remarkable  features  of  the  treatment.  Accepting  the  theory  that 
»  pain  from  an  inflammation  is  due  to  irritation  of  the  cells  and  end 
organs  by  toxins,  as  well  as  to  the  high  specific  gravity  of  the  inflam- 
matory exudate,  its  relief  under  the  influence  of  hyperemia,  which 
both  destroys  and  dilutes  toxins  and  also  dilutes  the  exudates,  may 
be  readily  understood.  If  pain  be  not  relieved,  or  at  least  mitigated, 
or  if  discomfort  results  from  the  treatment,  the  operator's  technic  is 


PASSIVE   HYPEREMIA  205 

probably  at  fault.  The  patient  should  always  be  impressed  with  the 
necessity  of  reporting  any  discomfort  in  the  part  subjected  to  the 
hyperemia,  and  his  sensations  should  be  an  important  guide  for  the 
operator. 

Through  the  prompt  decrease  of  pain  and  sensitiveness,  reflex 
contracture  of  muscles  is  avoided  and  earlier  motion  in  a  part  is  pos- 
sible. This  is  especially  important  in  infections  involving  tendon 
sheaths  and  joints,  as  with  early  motion  much  better  functional  re- 
sults are  possible.  Even  in  an  extremely  sensitive  joint,  it  is  remark- 
able how  quickly  slight  motion  may  be  painlessly  practised  under 
hyperemia. 

Bactericidal  Action. — It  has  been  shown  by  experiments  upon 
animals  as  well  as  by  clinical  evidence  that  through  hyperemia  cer- 
tain forces  are  brought  to  bear  which  either  directly  or  indirectly 
antagonize  bacterial  growth  and  either  destroy  or  dilute  the  toxins. 
Beginning  infection,  such  as  a  furuncle  or  a  carbuncle,  in  which  red- 
ness, tenderness,  swelling,  and  slight  infiltration  are  the  only  signs 
present,  can  thus  often  be  made  to  subside  without  suppuration, 
while,  if  suppuration  has  already  developed,  the  infectious  process 
may  be  prevented  from  extending  to  the  deeper  tissues  and  the  cKn- 
ical  course  be  greatly  shortened.  Accidental  soiled  wounds,  which 
from  experience  we  have  every  reason  to  beHeve  will  become  infected, 
under  the  influence  of  hyperemia  can  often  be  made  to  heal  without 
infection,  and  not  infrequently  by  primary  union,  and  there  is  no 
better  means  than  the  increased  secretion  induced  by  the  hyperemia 
for  thoroughly  flushing  out  and  rapidly  cleansing  these  dirty  wounds. 

There  is  considerable  difference  of  opinion  as  to  the  agent  under- 
lying this  bactericidal  action,  and  several  theories  have  been  advanced 
in  explanation.  Some  believe  that  it  is  due  to  an  increase  in  the 
phagocytes;  some  consider  the  carbonic  acid  of  the  venous  blood  to  be 
the  agent;  others  offer  Wright's  theory  as  to  increase  of  the  opsonic 
index  as  the  beneficent  factor;  and  still  others  claim  that  the  in- 
creased transudate  induced  by  the  hyperemia  mechanically  flushes 
out  the  affected  part  and  thereby  dilutes  the  toxins  and  removes  dead 
bacteria.  It  is  difficult  to  say  which  is  the  exact  cause.  Bier  him- 
self, I  believe,  inclines  to  the  phagocytosis  theory.  Personally,  the 
writer  feels  that  the  mechanical  flushing  of  the  part  by  the  increased 
transudate  is  quite  an  important  factor,  especially  in  the  presence  of 
open  wounds  or  sinuses. 

Limitation  of  the  Pathological  Process. — Under  hyperemia,  necrosis 
of  even  badly  damaged  parts  is  often  prevented  by  the  superabundant 


2o6  bier's  hyperemic  treatment 

nourishment  of  the  tissues,  or,  when  the  infection  has  advanced  to  the 
destruction  of  tissues,  the  disease  process  is  more  promptly  localized, 
and  a  line  of  demarcation  between  the  healthy  and  diseased  tissues  is 
earlier  in  evidence.  Sloughs  and  sequestra  are  thus  early  separated 
and  cast  off,  while  in  tubercular  aft'ections  connective  tissue  replaces 
the  tubercular,  and  the  disease  gradually  dies  out. 

Solvent  and  Absorbent  Action. — Both  the  active  and  the  passive 
forms  of  hyperemia  act  as  solvents,  while  the  active,  in  addition,  has 
a  very  marked  absorbent  action.  The  products  of  inflammation,  as 
infiltrations,  exudates,  and  plastic  changes,  are  dissolved,  so  to  speak, 
and  their  absorption  is  thus  favored.  Careful  application  of  hyper- 
emia thus  makes  unnecessary  many  of  the  operations  of  resection,  etc. 
This  is  well  illustrated  in  the  excellent  functional  results,  with  free- 
dom from  ankylosis  and  deformity,  obtained  in  tubercular  and  other 
joint  affections. 

Indications. — Passive  hyperemia  has  been  recommended  for  all 
kinds  of  acute  inflammatory  processes  and  many  of  the  chronic  ones, 
and  the  literature  of  the  past  few  years  teems  with  numerous  favor- 
able reports  of  its  use,  not  only  in  purely  surgical  affections,  but  in 
the  specialties  and  in  medicine  as  well. 

The  surgical  conditions  in  which  it  has  been  found  to  be  especially 
beneficial  may  be  summarized  as  follows:  Acute  infections  and  in- 
flammations, such  as  furuncles,  carbuncles,  felons,  infected  wounds, 
infection  of  tendon  sheaths,  lymphangitis,  lymphadenitis,  mastitis, 
gonorrheal  arthritis,  and  other  forms  of  acute  infections  of  joints, 
acute  bone  infections,  burns;  as  a  prophylactic  measure  in  soiled  or 
dirty  wounds,  compound  fractures;  in  chronic  afi'ections,  such  as 
tuberculosis  of  bones,  joints,  glands,  tendon  sheaths,  testicles;  delayed 
union  of  fractures;  fistulae;  old  discharging  sinuses;  and  infected  leg 
ulcers  uncompHcated  by  varicose  veins.  Its  use  is,  however,  contra- 
indicated  in  lesions  compHcated  by  thrombosis  of  veins.  In  ery- 
sipelas its  value  is  doubtful;  in  fact,  erysipelas  has  been  known  to 
develop  under  prolonged  h}^eremia  in  tubercular  lesions  which  were 
complicated  by  open  sinuses.  In  diabetes,  likewise,  the  results  have 
not  always  been  good. 

Passive  hyperemia  has  also  been  employed  with  success  in  medi- 
cine for  such  conditions  as  acute  rheumatism,  gout,  and  pulmonary 
tuberculosis.  For  the  latter  condition  Kuhn  has  devised  a  mask  of 
thin  celluloid  which  by  means  of  an  adjustable  valve  cuts  off  some  of 
the  air  entering  the  alveoli  and  thus  induces  a  suction  hyperemia. 
In  a  host  of  other  affections  falling  within  the  domain  of  rhinology, 


PASSIVE    HYPEREMIA  207 

otology,  gynecology,  obstetrics,  and  dermatology,  passive  hyperemia 
has  been  recommended  and  appHed  with  varying  degrees  of  success. 

General  Principles  Underlying  Hyperemic  Treatment. — As  em- 
phasized by  the  author  of  this  method  of  treatment,  and  others,  it  is 
not  a  panacea  or  cure  for  all  troubles.  One  should  recognize  that  it 
has  its  limitations.  In  some  of  the  milder  forms  of  infection,  com- 
plete cure  may  often  be  effected  by  hyperemia  alone;  in  other  cases, 
of  the  more  severe  infections,  it  forms  only  a  part  of  the  treatment, 
and  operative  interference  should  never  be  delayed  when  indicated. 
Pus  ?nust  always  be  promptly  evacuated,  and  cold  abscesses  likewise 
are  to  be  opened.  This  is  accomplished  by  small  incisions  or  punc- 
tures, the  old-time  extensive  incisions,  which  often  result  in  unsightly 
scars  and  even  deformities,  being  unnecessary  under  this  form  of 
treatment.  The  hemorrhage  incident  to  such  incisions  should  be 
controlled  by  packing  the  wound  for  two  to  three  hours  before  the 
hyperemia  is  induced.  In  an  infection  of  the  tendon  sheaths,  the 
anatomy  of  the  parts  should  be  carefully  kept  in  mind  and  the  inci- 
sions made  accordingly.  Small  multiple  incisions  are  employed  and 
should  be  so  placed  as  to  avoid  cutting  the  transverse  palmar  liga- 
ments opposite  the  finger  joints.  In  the  case  of  infection  of  a  large 
joint,  the  pus  is  aspirated  and  the  joint  cavity  is  irrigated  through  a 
large  trocar;  in  other  localities,  ordinary  surgical  principles  should  be 
the  guide  as  to  the  incision.  The  curettage  of  abscess  cavities  is 
avoided,  while  drains  and  tampons  are  discarded,  as  the  secretions 
that  are  poured  out  under  the  artificial  hyperemia  serve  to  keep  the 
wound  open.  Certain  cases  of  very  rapidly  extending  infection,  with 
acute  onset,  however,  require  early  incision  in  conjunction  with  the 
hyperemia,  even  before  softening  has  occurred.  If  incisions  are  not 
made,  the  hyperemia  may  do  harm  and  the  local  inflammation  be- 
come worse,  for  the  transudate  which  is  induced  by  the  hyperemia, 
added  to  the  exudate  already  present,  has  no  outlet  and  may  drive 
the  bacteria  and  their  toxins  into  healthy  tissue  and  favor  the  exten- 
sion of  the  infection. 

In  inflammations  involving  joints  or  tendon  sheaths,  mild  active 
and  passive  motion  are  carried  out  from  the  first  day,  in  order  to  obtain 
the  best  functional  results,  provided  this  can  be  done  without  pro- 
ducing pain.  Slight  motion  is  harmless  so  long  as  it  is  painless.  For 
this  reason,  no  immobilizing  dressing  need  be  applied  during  the 
treatment,  open  wounds  being  merely  covered  with  moist  antiseptic 
gauze. 

In  acute  infections,  the  results  are  often  prompt  and  most  strik- 


2o8  bier's  hyperemic  treatment 

ing.  In  favorable  cases,  the  temperature  declines,  pain  is  relieved, 
extension  to  deeper  tissues  is  prevented,  and  the  process  rapidly  sub- 
sides or  at  least  the  clinical  course  is  much  shortened.  Swelling  and 
redness  are  temporarily  increased,  and  are  to  be  expected  as  part  of 
the  treatment.  The  discharge  from  open  wounds  is  at  first  most 
abundant,  but  this  likewise  rapidly  subsides,  and  with  it  the  edema 
and  redness. 

In  chronic  lesions  of  a  tubercular  nature,  the  treatment  must  be 
carried  out  for  months.  In  the  case  of  joints,  the  pain  and  swelling 
slowly  diminish,  the  contour  of  the  joint  again  becomes  distinguish- 
able, and  mobility  gradually  increases;  secretions  from  sinuses  be- 
come serous  instead  of  purulent,  the  sinus  taken  on  a  healthy  appear- 
ance and  finally  closes.  In  tubercular  affections,  likewise,  slight 
motion  of  the  affected  limb  is  allowed,  provided  it  produces  no  pain. 
Fixation  of  the  joint,  in  cases  of  tuberculosis  of  the  wrist,  elbow,  or 
shoulder  can  thus  usually  be  dispensed  with — a  sling  at  most  is  used — 
but  in  knee  or  foot  tuberculosis  a  suitable  apparatus  should  be  worn, 
or  the  part  so  immobilized  by  a  movable  splint  when  the  patient  is 
moving  about  that  pressure  is  removed  from  the  diseased  articular 
surfaces.  In  the  presence  of  contractures  of  the  joints,  suitable 
extension  is  applied  and  used  in  conjunction  with  the  hyperemic 
treatment. 

Bier  gives  as  contraindications  to  the  use  of  hyperemia  in  tuber- 
culosis of  joints  the  following: 

1.  Commencing  amyloid  disease  and  advanced  pulmonary 
involvement. 

2.  Large  abscesses,  filling  up  the  whole  joint  cavity  and  demand- 
ing operation. 

3.  Faulty  position  of  the  joint,  such  that  cure  would  give  a  joint 
less  useful  than  could  be  obtained  by  resection.  In  such  conditions 
he  advises  operative  interference. 

Successful  hyperemic  treatment  necessitates  correct  technic,  and 
many  of  the  poor  results  at  first  obtained  by  those  unfamiliar  with 
this  method  may  be  ascribed  to  errors  in  this  direction.  It  certainly 
requires  time  and  close  attention,  as  well  as  considerable  experience 
on  the  part  of  the  attendant,  to  obtain  good  results;  but,  if  the  treat- 
ment be  properly  carried  out  with  perseverance,  one  will  be  amply 
repaid.  At  first  the  patient  must  be  carefully  watched  as,  with  the 
use  of  the  elastic  band,  for  instance,  it  may  be  necessary  to  remove  or 
reapply  the  constriction  several  times  in  the  course  of  a  single  treat- 
ment in  order  to  maintain  the  proper  degree  of  hyperemia.     Intelli- 


PASSIVE   HYPEREMIA 


209 


gent  patients  may  later  be  instructed  in  carrying  out  the  treatment 
with  either  the  bandage  or  the  cup,  and  in  time  they  themselves  can 
apply  the  treatment  at  home,  but  they  should  always  remain  under 
the  supervision  of  the  surgeon. 

Methods  of  Producing  Passive  Hyperemia. — As  already  indicated 
the  passive  form  of  hyperemia  may  be  obtained  by  means  of  soft 
rubber  bandages  or  by  special  suction  apparatus.  The  principle  in 
each  is  the  same,  but  the  technic  requires  special  description. 

Passive  Hyperemia  by  Means  of  Constricting  Bands. — This 
is  the  oldest  method  of  producing  an  obstructive  hyperemia.  It  is 
especially  applicable  to  affections  involving  the  extremities,  head, 
and  neck.  The  hip-joint  is  the  only  one  in  either  of  the  extremities 
to  which  the  method  cannot  be  satisfactorily  applied.  There  is  no 
doubt  that  the  proper  application  of  the  band  requires  more  skill 
than  does  cupping.     Exact  technic  is  necessary,  and  great  caution 


Fig.   182. — Esmarch  elastic  bandage  for  obstructive  hyperemia. 

must  be  observed  not  to  exceed  the  proper  grade  of  hyperemia,  and 
in  tubercular  cases  not  to  lower  the  vitality  of  the  tissues  by  too  pro- 
longed obstruction.  Only  a  mild  hyperemia  is  necessary  to  produce 
results;  otherwise,  distinct  harm  is  done.  For  this  reason,  the  band- 
age should  be  applied  by  the  surgeon  himself  until  an  intelligent 
and  competent  person  of  the  household  can  be  instructed  in  its 
proper  application. 

Apparatus. — For  most  cases,  a  soft,  thin  elastic  bandage,  such  as 
Esmarch's  or  Martin's,  about  2  1/2  inches  (6  cm.)  in  breadth,  is 
employed  (Fig.  182). 

For  the  shoulder-joint  and  testicles,  rubber  tubing  is  used  in  place 
of  a  bandage.  That  used  about  the  shoulder  should  be  of  fairly 
stout  rubber,  and  about  a  foot  long  (30  cm.) ;  while  for  the  scrotum, 
a  catheter  or  a  piece  of  drainage-tube  of  small  size  answers. 

To  produce  hyperemia  of  the  head  and  neck,  a  rubber  bandage 

measuring  about  i  1/4  inches  (3  cm.)  in  width  may  be  used,  or  a 

special  neck-band  made  for  the  purpose  may  be  obtained.     A  garter 

elastic,  about  i  inch  (2.5  cm.)  in  width  and  provided  with  hooks  and 

14 


2IO  BIER  S    HYPEREIKIC    TREATMENT 

eyes  so  that  it  may  be  adjusted  to  any  size,  as  shown  by  the  ac- 
companying illustration  (Fig.  183),  answers  the  purpose  admirably. 
Site  of  Application. — The  constriction  should  always  be  applied 
over  healthy  tissue  and  well  above  the  area  of  inflammation.  In 
involvement  of  the  hand,  for  instance,  the  bandage  is  applied  above 
the  elbow,  and  above  the  knee  if  the  foot  be  the  seat  of  trouble.  To 
avoid  undue  compression  continually  at  the  same  spot,  it  is  well  to 
change  the  location  of  the  bandage  at  each  application,  moving  it  a 
little  either  up  or  down  the  limb. 


Fig.   T83.— Elastic    garter    for   producing  obstructive  hyperemia  of   the    neck. 
(After  Meyer-Schmieden.) 

Duration  of  Application. — In  the  treatment  of  acute  processes, 
the  best  results  are  obtained  from  prolonged  stasis,  namely,  from 
twenty  to  twenty- two  hours  a  day.  The  bandage  is  accordingly 
applied  for  ten  or  eleven  hours,  then  discarded  for  two  or  one  hours, 
and  reapplied  for  another  ten  to  eleven  hours.  The  bandage  is 
applied  daily  and,  as  the  condition  improves,  the  duration  of  the 
daily  constriction  may  be  diminished  until  it  is  only  of  from  one  to 
two  hours. 

For  tubercular  affections  shorter  applications  are  used,  the  band- 
age being  applied  once  or  twice  a  day  from  one  to  four  hours  at  a 
time.  In  his  early  work  on  tubercular  affections.  Bier  first  employed 
short  periods  of  hyperemia,  and  then  prolonged  and  almost  con- 
tinuous hyperemia,  but  he  experienced  many  failures  and  bad  results 
with  the  latter.  He  found  that  prolonged  stasis  in  this  class  of 
cases  was  apt  to  devitalize  the  parts  and  lead  to  the  rapid  formation 
of  cold  abscess,  as  well  as  to  the  development  of  septic  abscess, 
lymphangitis,  adenitis,  erysipelas,  etc.,  so  that  he  returned  to  the 
short  applications  of  from  one  to  four  hours  a  day.  In  cases  of 
acute  hot  abscess  formation,  however,  due  to  a  mixed  infection  of 
open  sinuses,  the  application  may  be  extended  to  the  longer  periods 
■ — twice,  ten  or  eleven  hours — until  the  acute  process  has  subsided. 

Technic. — To  apply  the  bandage,  its  initial  extremity  is  first  wet 
sufljciently  to  make  it  adhere  to  the  skin  and  prevent  it  from  slipping. 


PASSR'E    HYPEREMIA 


211 


The  bandge  is  wound  around  the  hmb  with  moderate  tension  six  or 
eight  times  well  above  the  seat  of  disease,  each  layer  overlapping  the 
preceding  by  about  1/2  inch  (i  cm.).  The  bandage  is  then  made 
secure  by  adhesive  plaster  or  tapes  previously  sewed  to  the  terminal 
end  (Fig.  184). 

The  degree  of  h}'peremia  is  of  the  utmost  importance.  The 
object  is  to  moderately  constrict  the  veins  of  a  part,  without  in 
any  way  interfering  with  the  arterial  supply,  thereby  partly  checking 
the  reflux  of  blood  and  increasing  the  quantity  of  venous  blood  nor- 
mally present.  It  requires  practice  and  careful  attention  to  detail 
to  apply  the  bandage  in  such  a  way  that  the  arteries  are  not  com- 
pressed, while  at  the  same  time  the  right  amount  of  venous  obstruc- 
tion is  obtained.     If  the  constriction  is  applied  properly,  the  veins 


Fig.   184. — Showing  the  method  of  applying  the  elastic  bandage  to  the  arm. 


in  the  part  distal  to  the  bandage  become  slightly  distended,  and  the 
part  takes  on  a  bluish-red  hue  and  becomes  warm  to  the  touch.  This 
degree  of  hyperemia  is  essential,  as  the  hot  hyperemia  only  has 
therapeutic  value.  As  already  emphasized  the  pulse  should  never  he 
obliterated.  It  must  at  all  times  be  distinguished,  not  even  weakened. 
Furthermore,  the  application  of  the  bandage  should  never  cause  pain 
or  annoyance,  or  hj^eresthesia  of  the  part.  If  too  great  a  degree  of 
compression  is  employed,  nutritional  disturbances  from  the  increased 
stasis  injures  the  tissues  and  reduces  their  natural  resistance.  In 
such  a  case,  a  white  edema  is  produced,  or  the  skin  becomes  grayish- 
blue  in  color,  or  has  a  mottled  red  and  white  appearance,  and  the  part 
remains  cold  to  the  touch.  Such  a  condition  demands  removal  of 
the  bandage  and  its  proper  reapplication. 


212  BIER  S   HYPEREMIC    TREATMENT 

For  obtaining  the  proper  degree  of  hyperemia,  it  has  been  sug- 
gested that  a  sphygmomanometer,  such  as  the  Riva-Rocci  instru- 
ment, for  example,  be  employed.  The  cuff  is  secured  about  the  part 
in  the  same  manner  as  would  be  done  in  taking  the  blood-pressure 
and  the  systolic  pressure  is  estimated  (seepage  114).  The  mercury  is 
then  allowed  to  drop  about  10  mm.,  which  gives  the  proper  tension, 
after  which  the  tube  leading  to  the  inflation  band  is  tightly  clamped. 

In  chronic  cases  it  is  sometimes  very  difl&cult  to  obtain  the  proper 
amount  of  hyperemia,  and  several  procedures  have  been  advised  to 
increase  the  congestion.  Placing  the  part  in  a  bath  of  very  hot  water 
for  ten  minutes  before  the  constriction  is  applied  often  suffices.  In 
other  cases,  the  part  may  be  first  exsanguinated  by  means  of  an 
Esmarch  bandage,  as  would  be  done  preliminary  to  an  amputation, 
and  upon  removal  of  the  bandage  a  profuse  reactionary  flow  results, 
after  which  the  constrictor  is  applied. 

If  the  constriction  is  to  remain  in  place  for  long  periods  at  a  time, 
it  is  advantageous  to  apply  a  soft  flannel  bandage  beneath  the  rubber 
to  prevent  undue  pressure  upon  the  soft  parts,  which  might  produce 
an  irritation  of  the  skin,  or  even  atrophy  of  the  muscles.  This  is 
especially  necessary  when  treating  aged  or  thin,  flabby  individuals. 
While  the  bandage  is  in  place,  all  dressings,  splints,  etc.,  are 
removed  so  as  not  to  interefere  with  the  hyperemia.  If  open  wounds 
or  sinuses  be  present,  they  are  simply  covered  loosely  with  sterile  or 
antiseptic  gauze. 

A  marked  edema  results  from  the  hyperemia,  extending  up  to  the 
seat  of  constriction,  and  this  has  to  be  kept  within  proper  limits. 
When  the  application  is  only  for  short  periods  of  a  few  hours  each 
day,  the  edema  is  absorbed  spontaneously  in  the  intervals,  but  under 
prolonged  hyperemia  of  twenty  to  twenty-two  hours  the  time  for 
this  absorption  is  very  short,  and  it  is  often  not  possible  to  entirely 
reduce  it  between  applications.  Elevation  of  the  part  upon  pillows 
must  consequently  be  performed  during  the  intermissions.  Massage 
of  the  region  subjected  to  the  pressure  of  the  constriction  should  also 
be  practised  in  order  to  guard  against  pressure  atrophy. 

In  producing  hyperemia  of  the  shoulder-joint,  head  and  neck,  or 
testicles,  a  slight  variation  in  technic,  requiring  separate  description, 
is  necessary. 

Head  and  Neck. — About  the  neck  a  special  band,  already  de- 
scribed (page  2 10) ,  is  used.  It  should  be  applied  about  the  root  of  the 
neck,  well  below  the  larynx,  with  only  moderate  tension.  To  obtain 
the  greatest  degree  of  hyperemia  with  least  constriction,  small  pieces 


PASSIVE   HYPEREMIA  213 

of  felt  or  wadding  may  be  placed  under  the  constricting  band  on 
either  side  of  the  larynx  over  the  great  veins  (Fig.  185).  If  properly 
applied,  such  a  bandage  can  be  worn  with  entire  comfort.  It  causes 
a  pronounced  edema  of  the  face,  particularly  about  the  eyelids.  This 
is  no  contraindication  to  its  use,  however.  Care  should  be  taken  not 
to  apply  the  band  too  tightly — of  course  it  should  never  strangulate 
or  interfere  with  eating  or  swallowing.  If  throbbing  or  a  feeling  of 
marked  fullness  in  the  head  is  complained  of,  the  bandage  should  be 
removed  and  reapplied. 

Shoulder. — A  soft  bandage  or  cravat  is  placed  loosely  about  the 
patient's  neck  and  tied.  Through  the  loop  a  stout  piece  of  rubber 
tubing  about  a  foot  in  length  is  passed  as  a  ligature  encircling  the 
shoulder-joint,  the  middle  portion  being  placed  in  the  axilla  and  the 


Fig.   185. — Showing  the  appUcation  of  the  neck  band. 

two  ends  passing  up — one  in  front  and  the  other  behind  the  joint — to 
a  point  above  the  shoulder,  where  they  are  secured  by  tying  or  by 
means  of  a  clamp.  A  second  piece  of  bandage  is  secured  to  the  tub- 
ing in  front  of  the  joint,  and  passes  across  the  chest,  under  the  opposite 
axiUa,  and  around  the  back,  where  it  is  secured  to  the  portion  of  the 
rubber  ring  behind  the  joint  (Fig.  186).  By  adjusting  the  bandage 
and  regulating  the  tightness  of  the  rubber  tubing,  the  proper  degree 
of  constriction  may  be  obtained. 

For  anatomical  reasons  it  is  not  possible  to  change  the  location  of 
the  constrictor  at  each  application,  as  is  done  upon  the  extremities, 
and  great  care  and  attention  is  necessary  to  avoid  pressure  necrosis. 
For  this  reason,  it  is  better  to  apply  the  constriction  for  short  periods 
— say  three  or  four  hours — at  a  time,  repeated  several  times  in  the 


214 


BIER  S    HYPEREMIC    TREATMENT 


twenty-four  hours,   with   correspondingly   longer   intermissions,   in 
preference  to  the  ten  or  eleven  hour  applications. 

Scrotum. — Tubercular  and  other  affections  of  the  testicle  may  be 
treated  by  means  of  constriction  about  the  root  of  the  scrotum.     A 


Fig.    i86. — Showing    the    method    of    obtaining    obstructive    hyperemia    of    the 

shoulder. 


Fig.   187. — Showing  the  method  of  producing  obstructive  hyperemia  of  the  testicles. 

(After  Meyer-Schmieden.) 

small  piece  of  rubber  tubing  or  catheter  is  wound  several  times  about 
the  base  of  the  scrotum  over  a  layer  of  cotton  and  is  secured  in  place 
by  tying  with  a  piece  of  tape  or  cord  (Fig.  187). 


PASSIVE   HYPEREMIA  215 

Hyperemia  by  Means  of  Suction  Cups. — Innumerable  forms 
and  styles  of  suction  cups  for  producing  hyperemia  in  regions  not 
accessible  to  constriction,  as  well  as  large  chambers  for  use  upon  the 
extremities  and  large  joints,  have  been  devised.  The  hyperemia 
produced  by  these  devices  is  also  a  venous  one,  and  is  applicable  to 
the  same  class  of  cases  as  is  obstructive  hyperemia  by  the  bandage. 
As  with  the  use  of  the  constricting  band,  exact  technic  is  necessary, 
and  the  importance  of  obtaining  the  proper  degree  of  hyperemia 
cannot  be  too  strongly  emphasized. 

When  one  of  the  cups  is  applied  to  a  surface  and  a  vacuum  pro- 
duced, the  skin  and  underlying  tissues  are  sucked  into  the  chamber 
and  venous  stasis  with  a  consequent  increase  in  the  supply  of  blood 
in  the  skin  and  deeper  layers  result.  Besides  producing  hyperemia, 
the  mechanical  effect  of  the  cupping  glass  is  also  of  distinct  advantage. 
From  an  open  discharging  wound  pus  and  broken-down  tissues 
are  rapidly  and  effectually  aspirated.  Small  sequestra  of  bone  are 
often  quickly  separated  and  discharged  through  a  sinas  under  the 
influence  of  the  hyperemia  combined  with  suction.  In  the  presence 
of  tubercular  sinuses,  daily  applications  of  the  suction  cups  may  be 
employed  in  conjunction  with  the  rubber  bandage. 

Apparatus. — Cups  suitable  for  furuncles,  styes,  carbuncles,  breast 
abscess,  etc.,  chambers  in  which  are  placed  the  fingers,  hands,  feet, 
and  large  joints,  as  well  as  apparatus  to  be  used  by  the  gynecologist, 
orthopedist,  otologist,  and  other  specialists  are  now  manufactured. 
Types  of  some  of  these  are  shown  in  the  following  illustrations  (Figs. 
188  to  198).  If  there  is  considerable  discharge,  a  type  of  cup  shown 
in  Fig.  189  will  be  found  most  useful. 

In  selecting  the  cup,  one  should  be  chosen  of  sufiiciently  large 
diameter  to  extend  well  outside  the  limits  of  an  acute  inflammation, 
and  with  edges  that  are  thick  and  smooth,  in  order  to  avoid  undue 
pressure  upon  the  skin.  In  the  smaller  glasses  the  suction  is  obtained 
by  means  of  small  rubber  bulbs.  With  the  larger  apparatus,  stronger 
suction  is  required  and  a  special  exhausting  pump  is  necessary  (Fig. 
199).  A  further  convenience  for  use  with  the  larger  apparatus  is  a 
three-way  stopcock  inserted  between  the  glass  chamber  and  the 
pump  to  allow  admission  of  air  when  the  negative  pressure  is  too 
great  or  is  to  be  discontinued. 

In  addition  to  these  cups  and  chambers,  larger  and  stronger  appa- 
ratus for  orthopedic  use  is  made  for  the  purpose  of  bending  stiff 
joints  by  atmospheric  pressure,  as  shown  by  Fig.  200.  Here  the  arm 
is  drawn  firmly  in  the  glass  case  as  the  air  is  exhausted  until  the  hand 


2l6 


bier's  hyperemic  treatment 


meets  the  obstacle  at  the  lower  end  of  the  chamber,  when  the  wrist 
turns  in  the  direction  of  least  resistance.     Other  joints  of  the  body 


Fig.  198. 

Fig.  188. — Cup  for  sty.  189.  Cup  for  small  abscess.  190.  Cup  for  large 
abscess.  191.  Cup  for  gums.  192.  Cup  for  carbuncle.  193.  Cups  for  ton- 
sils. 194.  Breast  cup.  195.  Cup  for  cervix.  196.  Cup  for  nose.  19 7- 
Finger  suction  glass.      198.     Hand  suction  glass. 

may  be  similarly  treated  by  the  use  of  suitable  apparatus.  Klapp 
has  also  devised  metal  chambers  which  are  provided  with  an  air 
pump  and  a  heavy  rubber  bag  for  obtaining  motion  in  a  partially 


PASSIVE   HYPEREMIA  21 7 

ankylosed  joint.  Upon  exhausting  the  air  in  the  apparatus,  the 
rubber  bag  descends  and  exerts  an  evenly  regulated  pressure  upon 
the  part  to  be  treated,  as  shown  in  Fig.  201. 


Fig.   199. — Pump  for  producing  a  vacuum  in  the  larger  cups  and  suction  glasses. 

Asepsis. — In  using  suction  apparatus  in  the  neighborhood  of  open 
wounds  or  sinuses,  strict  asepsis  should  be  observed.  To  avoid  all 
danger  of  adding  to  the  infection,  the  cups  should  be  boiled  before 


Pig.  200. — Showing  the  method  of  obtaining  motion  in  a  stiff  wrist  by  the  aid  of 

passive  hyperemia. 

used.     They  should  be  again  boiled  and  well  cleaned  before  being 
put  away. 


Fig.  201. — Showing  the  method  of  obtaining  motion  in  a  stiff  knee-joint  by  the 
aid  of  passive  hyperemia. 

Duration  of  Application. — In  the  use  of  cups,  brief  applications 
often  repeated  are  essential.     Accordingly,  the  cup  is  applied  for  five 


2l8 


BIER  S   HYPEREMIC   TREATMENT 


minutes,  and  is  then  removed  for  an  interval  of  two  or  three  minutes, 
to  allow  the  congestion,  edema,  and  swelling  to  subside.  The  cup  is 
then  again  applied  for  five  minutes,  and  an  entirely  fresh  supply  of 
blood  with  bactericidal  properties  is  brought  to  the  part,  the  entire 
treatment  consuming  about  three-quarters  of  an  hour. 

Technic.— Pus,  if  present,  is  always  to  be  evacuated  by  means  of  a 
small  incision  or  puncture,  as  previously  described,  before  application 
of  the  suction  apparatus. 

To  apply  the  cup,  the  edges  of  the  glass  are  first  moistened  with 
vaselin,  to  avoid  leakage  of  air.     Gentle  pressure  is  then  made  on  the 


Fig.  202. — Showing  a  cup  applied  to  a  carbuncle. 


bulb,  and  the  cup  is  placed  over  the  affected  region,  care  being  taken  to 
use  a  cup  that  is  large  enough.  Upon  releasing  the  bulb,  the  air  in 
the  cup  is  partly  exhausted,  causing  the  area  covered  by  the  cup  to 
be  drawn  up  into  it,  and,  if  a  proper  amount  of  suction  is  exerted, 
the  cup  adheres  to  the  surface  and  a  pronounced  hyperemia  results 
(Fig.  202).  If  the  application  is  made  over  an  open  infected  wound, 
pus  will  be  drawn  out,  accompanied  by  some  blood. 

The  importance  of  obtaining  just  the  proper  degree  of  hyperemia 
has  already  been  strongly  emphasized  and  is  reiterated  here.  It 
must  be  remembered  that  the  suction  should  be  just  sufficient  to 
slightly  decrease  the  outflowing  blood  without  interfering  with  the 
inflow.  The  object  is  to  produce  a  reddish-blue  color  of  the  part. 
.1  distinct  blueness  or  mottling  of  the  skin,  or  complaint  of  pain  on  the 
part  of  the  patient,  indicates  too  great  an  amount  of  suction  and  requires 
ivithdrawal  and  reap  plication   of  the   cup.     Pain   should   never   be 


PASSIVE   HYPEREMIA 


219 


produced  even  in  acutely  inflamed  regions.  Sometimes  more  than 
one  application  of  the  cup  is  necessary  before  the  proper  degree  of 
hyperemia  is  obtained.  With  the  suction  pump,  the  degree  of 
hyperemia  may  be  more  nicely  regulated.  In  this  case,  the  cup  with 
the  edges  well  lubricated  is  simply  applied  to  the  affected  region, 
and  the  air  is  slowly  exhausted  until  the  proper  degree  of  hyperemia 
is  induced.  If  the  vacuum  is  produced  too  rapidly,  it  is  apt  to  cause 
some  pain.  Should  it  be  found  that  too  great  a  degree  of  suction  is 
produced,  the  stopcock  may  be  opened  slightly  and  air  allowed 
to  enter  the  chamber  until  the  desired  degree  of  congestion  is  attained. 
In  the  use  of  the  large  chambers,  such  as  are  employed  for  the 
treatment  of  a  hand  or  foot,  the  member  to  be  subjected  to  hj^eremia 
is  first  coated  with  soap  or  vaselin  so  that  the  rubber  sleeve  will  more 
easily  sHp  over  the  skin  and  at  the  same  time  leakage  of  air  may  be 
avoided.  The  patient  then  thrusts  the  arm  or  foot  into  the  appara- 
tus, and  the  rubber  sleeve  is  bandaged  securely  about  the  limb  with 
a  rubber  bandage  (Fig.  203).  A  partial  vacuum  is  then  produced. 
This  causes  the  part  to  be  drawn  more  deeply  into  the  chamber,  and 


Fig.  203. — Showing  a  suction  glass  applied  to  the  hand. 

some  care  will  be  necessary  to  avoid  injuring  the  limb  by  suddenly 
drawing  it  against  the  closed  end  of  the  apparatus.  A  distinct 
hyperemia  of  the  whole  part  within  the  chamber  is  thus  produced, 
which  may  be  increased  or  lessened  at  will  by  increasing  or  decreas- 
ing the  amount  of  air  in  the  apparatus. 

During  the  intermissions  between  applications,  the  congestion 
may  be  relieved  by  elevation  if  the  part  be  an  extremity.  Discharge 
or  secretions  from  open  wounds  or  sinuses  should  be  removed  be- 
tween applications  by  gentle  bathing  of  the  part  with  warm  sterile 
water  or  some  antiseptic  solution.  At  the  end  of  the  treatment  the 
whole  part  should  be  gently  bathed  with  warm  solution,  and  all 
loose  exudate  or  necrotic  tissue  removed  with  forceps  or  sterile  gauze. 
A  simple  wet  dressing  is  then  appUed.  At  the  next  sitting,  if  a  crust 
has  formed  over  the  opening  or  sinus,  it  is  gently  removed  with 
forceps  and  the  treatment  is  continued  as  outlined  above. 


2  20  BIER  S  HYPEREMIC   TREATMENT 

The  suction  treatment  should  be  applied  daily  at  first.  The 
amount  of  pus  usually  rapidly  decreases  each  day,  first  becoming  less 
purulent  and  more  serous,  until  finally  only  a  little  serum  is  with- 
drawn with  each  application.  The  swelling  diminishes  and  the  part 
begins  to  regain  its  normal  appearance  and  dimensions.  As  the 
suppuration  decreases,  the  treatment  may  be  given  every  second  day, 
and  finally  every  third  day,  until  recovery  is  complete. 

ACTIVE  HYPEREMIA 

The  active  or  arterial  form  of  hyperemia  is  produced  by  means  of 
dry  hot  air.  Any  portion  of  the  body  when  subjected  to  heat  be- 
comes red  and  hyperemic  through  local  increase  in  the  supply  of 
arterial  blood.  The  effects  of  hot-water  bags,  hot  compresses,  hot 
povdtices,  hot  sand,  etc.,  are  all  familiar  examples  of  active  hyperemia. 
Hot  air  in  a  dry  form,  however,  is  the  most  effective  means  for  in- 
ducing such  a  hyperemia  on  account  of  the  high  degree  of  heat  that 
can  be  borne  without  discomfort.  A  part  may  be  subjected  to  the 
influence  of  dry  hot  air  of  a  temperature  of  212°  F.  (100°  C.)  or  more 
without  danger  of  producing  a  burn  or  other  injurious  effects.  On 
the  other  hand,  moist  heat  of  a  temperature  of  125°  F.  (52°  C.)  is 
capable  of  doing  distinct  harm,  and  is  unbearable  even  for  short 
periods. 

The  use  of  hot  air  as  a  therapeutic  agent  is  by  no  means  new, 
and  has  been  employed  with  varying  degrees  of  success  for  ages,  but 
the  methods  of  application  were  crude  and  often  unsatisfactory. 
Improvements  in  the  modern  baking  apparatus  have  placed  this 
method  upon  a  firm  basis,  and  properly  applied  in  certain  cases  active 
hyperemia  becomes  a  therapeutic  agent  of  distinct  value. 

Indications. — Active  hyperemia  has  a  solvent  and  absorbent 
action  upon  exudate^,  infiltrations,  adhesions,  etc.,  and  a  marked 
analgesic  effect,  causing  a  sensitive  part  to  become  less  so  or  to  be 
entirely  reUeved  soon  after  the  appHcation  is  begun.  It  thus  acts 
favorably  in  chronic  rheumatism,  chronic  arthritis,  chronic  synovitis, 
and  arthritis  deformans.  It  aids  greatly  in  promoting  the  absorption 
of  edemas  and  of  effusions  of  blood  into  the  soft  parts,  and  in  synovial 
sacs — as  in  traumatic  synovitis.  Other  affections  in  which  active 
hyperemia  has  given  good  results  are  neuralgia,  sciatica,  neuritis, 
lumbago,  gout,  varicose  veins,  varicose  ulcers,  etc. 

In  fractures  near  a  joint  with  painful  involvement  of  the  joint 
itself,  it  is  of  great  value  in  reducing  the  edema  and  at  the  same 


ACTIVE    HYPEREMIA 


221 


time  hastening  the  repair,  thus  increasing  the  chances  of  obtaining  a 
more  useful  hmb  through  the  abihty  to  perform  early  passive  motion. 
In  a  CoUes'  fracture,  for  example,  the  bones  should  be  properly  re- 
duced and  within  a  few  days  the  part  should  be  daily  subjected  to 
the  influence  of  heat.  After  ten  days  the  splint  may  be  discarded 
entirely,  unless  there  seems  a  likelihood  that  the  deformity  will  recur, 
and  the  hot-air  treatment  is  daily  continued,  with  the  addition  of 
both  active  and  passive  motion. 


Fig.  204. — Apparatus  for  applying  active  hyperemia  to  the  hand  and  wrist  and  the 
method  of  its  application. 

While  active  hyperemia  is  of  distinct  therapeutic  value,  it  should 
not  be  employed  to  the  exclusion  of  other  means  of  treatment. 
Internal  medication  should  always  be  carried  out  when  the  condition 
is  such  that  it  seems  indicated,  and  the  hot-air  treatment  used  as  an 
adjunct.  In  affections  of  the  joints,  neuralgias,  etc.,  massage  should 
form  an  important  part  of  the  treatment.  Too  much  stress  cannot 
be  laid  on  the  value  of  massage  when  judiciously  used  in  the  ap- 
propriate class  of  cases. 

Apparatus. — Active  hyperemia  may  be  induced  either  by  the  use 
of  hot-air  boxes  or  hot-air  douches.  There  are  many  makes  of  hot- 
air  boxes  on  the  market.  The  simplest  are  made  of  cotton-wood 
carefully  fitted  together  and  covered  with  cloth  to  prevent  any  leakage 
of  air.     They  are  provided  with  a  lid  and  have  openings  at  one  or 


222 


BIER  S    HYPEREMIC    TREATMENT 


both  ends  for  receiving  a  limb.  These  openings  are  lined  with  cuffs 
of  felt  to  avoid  any  danger  of  burning  the  skin,  and  are  provided  with 
straps  so  that  the  cuffs  may  be  securely  fastened  to  a  limb.  Open- 
ings for  hot  air  are  provided  on  both  sides  of  the  box,  the  one  not  in 
use  being  shut  by  a  slide.  Into  one  of  these  a  chimney  is  fitted 
through  which  the  hot  air  is  conducted  from  the  heating  apparatus. 
The  heat  is  supplied  by  an  alcohol  lamp  or  a  gas  burner  secured  to  a 
bracket  so  that  the  lamp  may  be  raised  or  lowered  at  will.  The  lids 
have  one  or  more  openings  for  ventilation  of  the  apparatus.     The  air 


-^     ^ 


Fig.  205. — The   hot-air  douche  being   applied  in   sciatica.      (The  nozzle   of  the 
apparatus  should  be  shown  directed  more  to  the  posterior  surface  of  the  limb.) 

is  thus  constantly  in  motion,  which  is  important  in  order  to  permit 
evaporation  of  the  perspiration  upon  the  part  and  to  maintain  the 
dryness  of  the  air,  A  thermometer  is  also  provided  with  each  box 
for  indicating  the  temperature.  Such  boxes  are  made  to  fit  various 
parts  of  the  body,  as  the  arm,  hand,  shoulder,  foot,  knee,  hips,  etc. 

Hot-air  douches  may  also  be  obtained  for  use  over  small  areas,  as 
along  the  course  of  a  nerve,  about  the  ear,  etc.  The  douche  consists 
of  a  long  metal  movable  chimney,  underneath  which  is  the  lamp  or 
gas  burner  (Fig.  205). 

Temperature. — The  degree  of  heat  to  which  the  part  is  subjected 
may  vary  from  150°  F.  to  212°  F.  (60°  C.  to  100°  C.)  or  even  higher. 
The  temperature  must  never  be  high  enough,  however,  to  cause  dis- 


BISMUTH    PASTE    INJECTIONS  223 

comfort,  and  the  patient's  feelings  should  be  the  guide.  It  should  be 
remembered  that  the  prolonged  application  of  a  very  high  degree  of 
heat  lowers  the  sensibility  of  a  part,  and  great  care  must  be  taken  not 
to  burn  the  patient;  the  same  caution  must  be  observed  when  apply- 
ing active  hyperemia  to  tissues  with  lowered  resistance.  A  moderate 
temperature  should  be  employed  at  the  start,  and  this  should  be 
increased  gradually  as  tolerance  is  attained.  The  temperature  is 
regulated  by  raising  the  lamp  nearer  the  box  or  moving  it  farther 
away,  and  also  by  the  size  of  the  flame. 

Duration  of  Applications. — The  heat  should  be  applied  from  half 
an  hour  to  an  hour  daily,  or  on  alternate  days.  In  exceptionally 
stubborn  cases  it  may  be  applied  for  the  same  length  of  time  twice 
daily. 

Technic. — The  patient  assumes  a  comfortable  attitude,  either 
seated  or  lying  down,  with  the  apparatus  close  at  hand.  The  part 
to  be  baked  is  then  placed  in  the  box  and  the  lid  is  closed.  The  lighted 
lamp  is  placed  under  the  funnel  and  the  temperature  is  gradually 
raised  until  a  degree  of  heat  is  attained  that  can  be  comfortably  borne 
by  the  patient.  The  vent  in  the  top  of  the  apparatus  should  always 
be  open  when  it  is  in  use,  in  order  to  obtain  the  necessary  draught  for 
the  flame  and  proper  ventilation  of  the  apparatus.  When  the  desired 
degree  of  temperature  has  been  reached,  it  should  be  maintained  from 
half  an  hour  to  an  hour.  The  light  is  then  extinguished  and  the 
temperature  is  allowed  to  slowly  fall  before  the  member  is  removed. 
A  sudden  change  of  temperature,  such  as  would  be  occasioned  by 
immediately  removing  the  part  to  the  outside  atmosphere,  is  to  be 
avoided.  The  part,  when  removed  from  the  baking  apparatus,  is 
hot  and  hyperemic  and  remains  so  for  some  little  time.  Immediately 
following  the  treatment,  gentle  massage  and  passive  motion,  if 
indicated,  should  be  practised. 

THE  DIAGNOSIS  AND  TREATMENT  OF  FISTULOUS  TRACTS 
BY  MEANS  OF  BISMUTH  PASTE 

The  injection  of  a  mixture  of  bismuth  and  vaselin  for  the 
diagnosis  and  treatment  of  fistulae,  tubercular  sinuses,  and  abscess 
cavities  was  devised  by  Beck  of  Chicago.  He  originally  employed 
the  method  for  the  purpose  of  determining  the  size,  course,  and  ex- 
tent of  fistulous  tracts.  His  first  injection  of  a  fistula  for  diagnostic 
purposes  resulted,  however,  in  the  prompt  closure  of  the  sinus,  and 
led  him  to  extend  the  use  of  the  injections  to  curative  purposes  with 
most  favorable  results. 


224 


BIER  S    HYPEREMIC    TREATMENT 


For  diagnostic  purposes  the  fistula  or  abscess  cavity  is  filled  with 
the  bismuth  mixture  and  then  a  radiograph  is  taken.  As  the  bis- 
muth offers  great  resistance  to  the  penetration  of  the  X-rays,  a  clear 
shadow  is  obtained  of  the  fistula  and  all  its  ramifications.  This 
gives  much  more  information  than  the  usual  methods  of  probing  and 
injecting  colored  fluids,  peroxid,  etc. 

As  a  therapeutic  measure  the  method  of  application  is  equally 
simple,  the  bismuth  paste  being  injected  into  the  fistula  or  abscess 
cavity  and  allowed  to  remain  there.  Later  it  is  absorbed.  It 
is  claimed  that  the  bismuth  has  a  bactericidal,  chemotactic,  and 
astringent  action  on  the  tissues.  Furthermore,  through  its  me- 
chanical effect,  it  promotes  healing  by  keeping  the  walls  of  the  sinus 
separated  and  forming  a  framework  for  the  granulating  tissue  to 
work  through.  The  method  is  applicable  to  all  fistulae  or  abscess 
cavities  except  biliary  or  pancreatic  fistulae  and  those  communicating 
with  the  cranial  cavity  or  urinary  bladder.  It  is  contraindicated 
in  acute  processes  and  new  sinuses,  as  absorption  occurs  very  readily 


Fig.   206. — Types  of  syringe  for  bismuth  paste  injections. 

from  the  fresh  lining  of  the  walls.  In  old  sinuses  and  abscess  cavities 
this  is  not  the  case,  the  thick  fibrous  walls  possessing  a  greatly  dimin- 
ished power  of  absorption. 

Toxic  effects  have  been  observed  after  the  use  of  bismuth  paste, 
and,  in  some  instances,  death  has  resulted.  The  symptoms  are  those 
of  nitrite  poisoning:  black  lines  upon  the  gums,  ulcerative  stomatitis, 
vomiting,  diarrhea,  albuminuria,  cyanosis,  and  collapse.  To  avoid 
this  danger  not  more  than  100  gm.  (3  ounces)  of  the  mixture  should 
be  injected  the  first  time,  and  the  patient  should  be  carefully  watched 
for  the  appearance  of  any  toxic  symptoms.  Should  they  develop 
the  cavity  must  be  promptly  evacuated.  This  may  be  accomplished 
by  injecting  into  the  cavity  some  warm  sterile  olive  oil  and  removing 
it  within  twenty-four  to  forty-eight  hours  by  aspiration.  The 
cavity  should  never  be  curetted,  as  this  simply  opens  up  new  chan- 
nels for  absorption. 


BISMUTH  PASTE   INJECTIONS  225 

Apparatus.— There  will  be  required  a  vessel  to  heat  the  bismuth 
mixture  in,  a  glass  rod  to  stir  the  mixture,  and  a  large  blunt-pointed 
glass  syringe  with  asbestos  packing.  For  injecting  rectal  fistula 
Beck  has  devised  a  syringe  with  a  nozzel  of  special  shape  and  curve 

(Fig.  206). 

'  Formulary. — Two  mixtures  are  used  by  Beck: 

No.  I.    Bismuth  subnitrate,  33% 

Vaselin,  67% 

No.  II.  Bismuth  subnitrate,  30% 

White  wax,  5% 

Soft  paraffin  (120°  F.  melting  point),  5% 

Vaselin,  60% 

Formula  No.  I  is  used  for  diagnostic  purposes  and  for  early  treat- 
ments, while  No.  II  is  used  for  late  treatments  after  the  discharge 
from  the  sinus  has  ceased.  Only  arsenic-free  bismuth  should  he  used. 
The  paste  is  mixed  by  melting  the  vaselin  and  while  still  hot  stirring 
into  it  the  bismuth.  It  is  claimed  that  the  efiiciency  of  the  paste  is 
increased  by  adding  1/2  to  i  per  cent,  formalin. 

To  avoid  the  dangers  of  nitrite  poisoning,  various  other  substances 
have  been  incorporated  in  the  vaselin,  such  as  the  subcarbonate, 
oxychlorid,  and  subgallate  of  bismuth,  chalk,  oxid  of  iron,  etc., 
but  in  the  opinion  of  Beck  they  are  inferior  to  bismuth  subnitrate  for 
therapeutic  purposes. 

Asepsis. — The  syringe  and  receptacle  for  warming  the  bismuth 
mixture  and  the  stirring  rod  should  be  sterilized  by  dry  heat.  If  the 
syringe  needs  lubricating  the  packing  may  be  dipped  in  sterile  olive 
oil.  The  paste  is  sterilized  by  heating  over  a  water  bath,  care  being 
taken  not  to  allow  any  water  to  come  in  contact  with  the  mixture. 

Preparations  of  the  Patient. — No  general  preparation  of  the  pa- 
tient is  necessary;  the  sinus  or  cavity  to  be  injected  may  be  dried 
out  by  means  of  a  strip  of  gauze  if  this  is  feasible,  but  no  irrigation 
should  be  attempted.  The  opening  of  the  sinus  is  carefully  wiped  off 
with  alcohol. 

Technic. — The  paste  is  heated  over  a  water  bath  and  is  stirred 
until  thin  enough  to  be  drawn  into  the  syringe.  The  syringe  is  then 
filled  with  the  melted  mixture,  the  point  of  the  syringe  is  pressed 
closely  into  the  mouth  of  the  sinus,  and  the  mixture  is  injected  under 
sufiicient  pressure  to  distend  and  penetrate  all  the  ramifications  of 
the  sinus.  Both  for  purposes  of  diagnosis  and  treatment  it  is 
absolutely  essential  that  the  paste  be  made  to  enter  all  portions  of 
the  tract.  When  the  patient  feels  a  sense  of  distention  from  the 
IS 


2  26  bier's  hyperemic  treatment 

injection,  the  latter  is  stopped  and  a  pledget  of  gauze  is  quickly  placed 
over  the  opening.  An  ice-bag  is  then  applied  to  the  part  and  the 
patient  is  kept  quiet  for  a  few  hours. 

As  a  rule,  after  the  first  injection,  the  secretions  change  in  char- 
acter and  become  first  seropurulent,  then  serous,  and  finally  cease. 
Should  the  discharge  continue  the  injection  may  be  repeated  at  the 
end  of  a  week  and  after  that  every  three  to  five  days  until  the  sinus 
closes.  If  any  improvement  is  going  to  take  place  it  should  be 
noticed  inside  of  a  month.  Tracts  that  show  no  disposition  to 
close  should  be  carefully  examined  for  the  presence  of  dead  bone 
or  other  foreign  body,  which,  if  present,  must  be  removed.  A  small 
per  cent,  of  the  cases  show  no  results  at  all  from  the  treatment. 


CHAPTER  X 

THF  COLLECTION   AND    PRESERVATION    OF  PATHO- 
LOGICAL  MATERIAL 

With  the  present-day  refinements  of  laboratory  methods,  the  aid 
furnished  by  an  examination  of  discharges,  blood,  urine,  sputum, 
etc.,  is  of  great  importance,  and  often  without  the  information  so 
obtained  a  correct  diagnosis  is  impossible.  It  is  not  within  the  scope 
of  this  work  to  enter  into  the  details  of  laboratory  methods — these 
may  be  found  in  books  devoted  to  the  subject — but  it  is  the  writer's 
purpose  in  this  section  to  give  brief  instructions  as  to  the  methods  of 
collecting  material  and  the  preparation  of  specimens  for  subsequent 
pathological  examination.  This  work  usually  falls  to  the  lot  of  the 
practitioner  or  surgeon  himself,  and  often,  through  faulty  technic 
in  the  inoculation  of  a  culture,  in  the  preparation  of  slides,  or  in  the 
collection  of  discharges,  etc.,  the  results  of  the  pathologist's  examina- 
tion are  misleading  or  useless. 

In  any  case  where  material  is  sent  to  a  laboratory  for  examination, 
each  specimen  should  be  clearly  labeled  with  the  name  of  the  patient, 
or  by  a  distinguishing  number,  with  the  clinical  diagnosis,  and  a  short 
cHnical  history  of  the  case,  together  with  a  statement  of  from  what 
part  of  the  body  or  from  what  organ  the  growth,  discharge,  or  what- 
ever.it  may  be,  was  obtained,  should  accompany  the  specimen.  If 
chemicals  have  been  employed  for  preserving  the  specimen,  this 
should  also  be  stated  on  the  slip  sent  to  the  pathologist. 

METHOD  OF  MAKING  A  SMEAR  PREPARATION  FOR 
MICROSCOPICAL  EXAMINATION 

Equipment. — A  number  of  clean  glass  sHdes,  sterile  swabs,  and 
suitable  specula  for  exposing  to  view  deep-seated  regions  from  which 
the  discharge  may  originate,  will  be  required. 

The  slides  should  be  absolutely  clean  and  free  from  grease. 
Unless  the  sKdes  are  very  dirty,  the  following  method  of  cleansing 
the  glass  will  suffice:  First  wash  off  the  sHde  with  soap  and  water, 
then  wipe  with  alcohol  and  ether  and  rub  dry  with  an  old  linen  or 
silk  cloth ;  finally  pass  the  slide  through  an  alcohol  flame.     When  once 

227 


228 


COLLECTION    OF   PATHOLOGICAL   MATERIAL 


cleansed,  care  should  be  taken  that  the  surface  of  the  slide  does  not 
come  into  contact  with  the  skin,  as,  if  it  does,  a  thin  tilm  of  grease 
will  be  left  upon  the  glass. 

The  swabs  consist  of  steel  wires  or  applicators  about  one  extremity 
of  which  some  cotton  is  wound.  They  may  be  obtained  sterilized 
and  ready  for  use,  or  may  be  easily  extemporized  as  follows:  A  test- 


FlG.   207. — Roughened  wire  for  making  a  swab. 

tube  and  a  piece  of  stiff  wire,  of  a  length  somewhat  longer  than  that 
of  the  tube,  are  obtained.  One  end  of  the  wire  is  first  roughened  with 
a  file  (Fig.  207)  and  is  then  tightly  wrapped  with  a  small  roll  of 
cotton  (Fig.  208).  The  swab  is  then  loosely  laid  in  the  test-tube  and 
the  mouth  of  the  tube  is  plugged  with  sterile  cotton  (Fig.  209),  and 


Fig.  208. — Showing  the  method  of  wrapping  cotton  on  the  end  of  a  wire. 

the  whole  is  sterilized  by  dry  heat.     A  supply  of  swabs  may  be 
prepared  in  this  way  and  be  kept  ready  for  use  almost  indefinitely. 

Technic. — The  slides  are  arranged  upon  a  towel  and  the  tubes 
containing  the  sterile  swabs  are  placed  near  at  hand.  With  the  seat 
of  the  disease  well  exposed,  the  swab  is  removed  from  the  glass 
container  and  dipped  into  the  pus  or  the  secretion,  care  being  taken 


Fig.   209. — Sterile  swab  in  a  glass  test-tube. 

that  it  touches  nothing  but  the  material  from  which  the  specimen  is 
to  be  obtained.  The  swab  is  then  rubbed  over  the  surface  of  one 
of  the  glass  slides  so  as  to  spread  the  material  in  a  thin  transparent 
film  (Fig.  210).  At  least  two  smears  should  be  made  from  each 
locality,  and  each  slide  should  be  labeled  with  a  distinguishing  number. 
The  slides  are  allowed  to  dry  and  are  then  piled  up  and  secured  one 


SMEAR  PREPARATION    POR    MICROSCOPICAL    EXAMINATION       229 

upon  another,  but  with  their  surfaces  separated  by  matches  or  tooth- 
picks, as  shown  in  Fig.  211. 


Fig.  210. — Method  of  making  a  smear. 

From  the  Mouth  and  Pharynx. — Equipment. — Sterile  swabs, 
glass  slides,  and  a  tongue  depressor  will  be  required  (Fig.  212.) 


Fig.  211. — Glass  slides  separated  by  match  sticks  and  held  together  with  rubber 
bands  ready  for  shipment  to  the  laboratory.      (Ashton.) 

Technic. — It  should  be  seen  that  no  antiseptic  mouth  washes  or 
gargles  have  been  used  for  at  least  two  hours  previous  to  the  time  the 
smear  is  made.     The  patient  is  seated  in  a  good  light,  with  his 


Fig.  212. — Instruments  for  taking  a  smear  from  the  pharynx,      i,  Sterile  swabs; 
2,  glass  slides;  3,  tongue  depressor. 

mouth  widely  opened,  and  the  tongue  controlled  by  the  tongue  de- 
pressor held  in  the  operator's  left  hand,  so  that  a  good  view  of  the 


230 


COLLECTION    OF    PATHOLOGICAL    MATERIAL 


diseased  area  may  be  obtained.  The  sterile  swab  is  then  removed 
from  its  container,  taken  in  the  right  hand,  and  is  passed  into  the 
mouth,  the  operator  being  careful  not  to  allow  it  to  come  in  contact 
with  the  lips  or  tongue.  When  in  contact  with  the  area  from  which 
the  material  is  to  be  obtained,  the  swab  should  be  rotated  about  so 
as  to  bring  as  much  as  possible  of  its  surface  in  contact  with  the 
secretions  (Fig.  213).  In  removing  the  swab  the  same  care  against 
contamination  from  contact  with  the  tongue,  etc.,  should  be  observed. 


Fig.  213. — Showing  the  method  of  taking  a  smear  from  the  pharynx. 


A  thin  smear  is  then  made  upon  a  slide  in  the  manner  described  above, 
and  the  swab  is  returned  to  its  container  for  future  inoculation  of 
culture  tubes  if  necessary. 

From  the  Nose. — Equipment. — Swabs,  slides,  a  nasal  speculum, 
a  head  mirror,  and  an  angular  pipette  (Fig.  214)  will  be  required. 

Technic. — Ordinarily,  for  microscopical  examination,  a  smear 
made  in  the  usual  way  from  secretions  blown  from  the  nose  into  a 
clean  handkerchief  is  sufficient.  If,  however,  it  is  desired  to  obtain 
a  smear  from  any  one  locaUty,  the  secretion  should  be  first  removed 
by  means  of  a  pipette  (page  243),  and  from  this  the  smear  is  made. 

From  the  Eyes. — Equipment. — Slides,  a  sterile  swab,  a  platinum 
needle,  and  an  alcohol  lamp  (Fig.  215)  will  be  necessary. 

Technic. — There  should  be  no  preliminary  cleansing  of  the  eyes. 
The  platinum  needle  is  first  sterilized  by  passing  it  through  the 


SMEAR   PREPARATION   FOR   MICROSCOPICAL   EXAMINATION 


2^1 


flame,  and  when  it  has  cooled  the  hds  are  separated,  the  loop  is 
brought  into  contact  with  the  pus  and  some  of  it  is  transferred 
to  a  slide.    A  smear  is  then  made  by  means  of  the  swab. 


Fig.  214. — Instruments   for  taking  a  smear  from  the  nose,     i,  Sterile  swab;  2, 
nasal  speculum;  3,  glass  slides;  4,  angular  pipette;  5,  head  mirror. 

From    the    Urethra. — Equipment. — Slides    and    sterile   swabs 
(Fig.  216)  should  be  provided. 

Technic. — In  a  male,  the  meatus  should  be  cleansed,  and  a  drop 


Fig.  215. — Instruments  for  taking  a  smear  from  the  eyes,      i,  Sterile  swab;  2, 
glass  slides;  3,  alcohol  lamp;  4,  platinum  needle. 

of  pus  is  expressed  by  stripping  the  urethra  with  the  finger  from 
behind  forward.  The  swab  is  then  dipped  in  the  pus  and  a  thin 
smear  is  made  upon  a  slide  in  the  usual  way. 


232 


COLLECTION    OF    PATHOLOGICAL    MATERIAL 


Fig.  2i6. — Instruments  for  taking  a  smear  from  the  urethra,      i,   Sterile  swab; 

2,  slides. 


Fig.  217. — Forcing  the  discharge  out  of  the  urethra  b}^  pressure  against  the  canal 
with  the  tip  of  the  finger  in  the  vagina.      (Ashton.) 


SMEAR   PREPARATION   FOR   MICROSCOPICAL   EXAMINATION       233 

In  the  female,  the  labia  are  held  apart  by  an  assistant,  the  index 
finger  is  inserted  in  the  vagina,  and  the  urethra  is  stripped  from 
behind  forward  (Fig.  217).  The  swab  is  then  brought  into  contact 
with  the  drop  of  pus  that  is  thus  expressed,  and  a  smear  is  made 
from  it  in  the  usual  way. 

From  the  Vagina. — Equipment. — Swabs,  slides,  and  a  vaginal 
speculum  (Fig.  218)  are  needed. 

Technic. — The  labia  are  separated  and  the  speculum  is  introduced 
so  as  to  obtain  a  good  view  of  the  parts.     The  swab  is  then  introduced 


Pig.  218. — Instruments  for  taking  a  smear  from  the  vagina,      i     Sterile  swab; 
2,  glass  slides;  3,  vaginal  speculum. 

without  touching  the  vulva  and  is  rubbed  in  the  discharge,  mucous 
patch,  or  whatever  it  may  be.  A  smear  is  then  made  from  the 
material  thus  obtained. 

From  the  Cervix. — Equipment. — A  long  swab,  a  speculum,  two 
tenacula,  a  sponge  holder,  and  glass  slides  (Fig.  219)  should  be 
provided. 

Technic. — The  speculum  is  introduced  so  that  the  cervix  is  well 
exposed  to  view,  and,  by  means  of  a  tenaculum  placed  in  each  lip, 
the  cervix  is  drawn  as  far  down  as  possible.  The  swab  is  then  passed 
into  the  cervical  canal  (Fig.  220),  but  care  is  taken  that  it  does  not 
enter  the  uterus  for  fear  of  carrying  infection  to  what  may  be  a  healthy 
organ  from  a  diseased  cervix.  The  swab  is  then  withdrawn,  and 
a  smear  is  made  in  the  usual  way. 


234 


COLLECTION    OF    PATHOLOGICAL    MATERIAL 


Fig,  219. — Instruments  for  taking  a  smear  from  the  uterus.      I,  Sterile  swab; 
2,  tenacula;  3,  Simon's  speculum;  4,  glass  slides;  5,  sponge  holder. 


Fig.  220. — Method  of  collecting  the  secretions  from  the  uterus.     (Ashton.) 


METHOD  OF  INOCULATING  CULTURE  TUBES  235 

METHOD  OF  INOCULATING  CULTURE  TUBES 

Equipment. — Culture  tubes,  sterile  swabs,  platinum  needles, 
thumb  forceps,  and  an  alcohol  lamp  (Fig.  221)  will  be  required. 

A  variety  of  media  are  employed  for  the  growth  of  bacteria,  such 
as  broth,  agar-agar,  gelatin,  and  blood  serum,  according  to  the  kind 
of  bacteria  to  be  cultivated.     The  culture  media  are  sold  in  sterile 


3i    Lm 


M 


H 


Fig.  221. — Instruments  for  making  a  culture,      i,   Alcohol  lamp;  2,  thumb 
forceps;  3,  sterile  swabs;  4,  culture  tubes;  5,  platinum  needle. 

test-tubes,  generally  plugged  with  cotton.  When  they  are  to  be 
kept  for  any  length  of  time,  the  tubes  should,  in  addition,  be  sealed 
with  rubber  caps  or  oiled  paper  to  prevent  their  contents  from  drying 
out. 

The  inoculation  of  the  tubes  is  performed  by  means  of  a  swab 
or  a  platinum  needle.     The  method  of  making  and  sterilizing  the 


Fig.   222. — Platinum  needles. 

former  has  been  described  above  (page  228).  The  needle  consists 
of  a  platinum  wire,  3  to  4  inches  (7.5  to  10  cm.)  long,  which  is  in- 
serted into  the  end  of  a  glass  rod  6  to  8  inches  (15  to  20  cm.)  long, 
which  serves  as  a  handle.  The  free  end  of  the  wire  may  be  made 
into  the  form  of  a  loop  or  it  may  be  simply  left  straight  (Fig.  222), 


236 


COLLECTION    OF    PATHOLOGICAL    MATERIAL 


according  to  whether  a  streak  or  a  stab  culture  is  to  be  made.  Before 
use,  the  wire  should  be  sterilized  by  passing  it  back  and  forth  through 
a  flame  for  a  few  seconds. 

Technic. — In  making  a  culture  the  greatest  care  must  be  exer- 
cised as  to  the  asepsis  and  the  avoidance  of  contamination.  The 
culture  tubes,  platinum  needles,  etc.,  are  arranged  upon  a  towel 
within  easy  reach,  and  the  alcohol  lamp  is  lighted.  The  end  of  the 
culture  tube  containing  the  cotton  plug  is  first  passed  through  the 
flame,  the  cotton  being  singed  so  as  to  destroy  any  germs  that  may 
be  deposited  upon  it  (Fig.  223).  The  culture  tube  is  held  between 
the  thumb  and  forefinger  of  the  left  hand,  with  the  mouth  of  the 


Fig.  223.-:-Singeing   the   cotton    stopper   of   a   culture   tube   preparatory   to   its 

inoculation. 


tube  pointing  downward,  if  it  contains  a  solid  medium,  so  as  to  pre- 
vent the  entrance  of  any  dust.  A  pair  of  thumb  forceps,  after  being 
passed  through  the  flame,  are  used  to  remove  the  cotton  plug  which 
is  then  transferred  to  the  left  hand  where  it  is  held  between  the  index 
and  second  fingers  while  the  culture  is  being  made. 

If  a  streak  culture  is  to  be  made,  a  looped  platinum  needle  is 
sterilized  by  passing  it  through  the  flame,  including  the  portion  of 
glass  handle  that  will  enter  the  tube,  and,  after  permitting  it  to  cool, 
the  tip  of  the  needle  is  dipped  into  the  secretion  or  pus — care  being 
taken  that  it  touches  nothing  else — and  is  passed  to  the  bottom  of 
the  culture  tube  and  then  gently  withdrawn  over  the  culture  medium 
so  as  to  spread  the  material  in  a  thin  streak  upon  its  sloping  surface 
(Fig.  224).     The  platinum  needle  is  again  passed  through  the  flame 


METHOD    OF   INOCULATING    CULTURE    TUBES 


237 


and  is  then  laid  aside.  The  tube  is  finally  closed  with  the  cotton 
plug,  fijst  singeing  the  cotton,  however,  in  the  flame  while  held  with 
the  thumb  forceps. 


Fig.  224. — Alethod  of  making  a  streak  culture.      (Levy  and  Klemperer.) 


Fig.  225. — Showing  "a"  stab  culture,  and  "b"  smear  culture. 

When  a  stab  culture  is  to  be  made,  a  straight  needle  is  employed 
instead  of  a  looped  one.  The  technic  is  precisely  the  same  as  for  a 
streak  culture  except  that  the  needle  is  inserted  straight  into  the 
culture  medium  and  is  then  withdrawn. 


238  COLLECTION    OP    PATHOLOGICAL    MATERIAL 

A  smear  culture  with  a  swab  is  made  as  follows:  The  culture  tube 
and  the  tube  containing  the  sterile  swab  are  held  side  by  side  between 
the  thumb  and  the  index  finger  of  the  left  hand.  The  cotton  plugs 
are  removed  with  sterile  forceps,  the  ends  of  the  tubes  and  the  ex- 
posed cotton  being  first  singed,  as  described  above.  The  cotton 
plugs  are  held  between  the  ring  and  little  finger  and  the  ring  and 
middle  fingers  of  the  left  hand,  while,  with  the  right  hand,  the  swab 
is  withdrawn  from  its  tube,  dipped  in  the  secretion,  and  is  then  in- 
serted into  the  culture  tube  and  is  rubbed  thoroughly  over  the  surface 
of  the  culture  medium  (Fig.  226).  The  swab  is  then  replaced  in  its 
container  and  the  cotton  plug  is  singed  and  reinserted  into  the  mouth 
of  the  culture  tube. 

When  a  number  of  cultures  are  being  made,  care  should  be  taken 
to  immediately  number  each  tube  as  it  is  inoculated. 


Fig,  226. — The  method  of  making  a  smear  culture. 

COLLECTING  DISCHARGES  AND  SECRETIONS  FOR  BACTERI- 
OLOGICAL EXAMINATION 

When  in  the  absence  of  culture  tubes  or  for  other  reasons  it  is 
necessary  to  send  fluid  material  to  a  laboratory  for  bacteriological 
examination,  it  is  best  collected  in  sterile  glass  pipettes  which  are 
then  hermetically  sealed.  This  insures  against  leakage  as  well  as 
any  chance  of  contamination  during  transportation. 

Equipment. — A  number  of  glass  pipettes,  a  rubber  suction  bulb  or 
a  suction  syringe,  an  alcohol  lamp,  scissors,  and  suitable  specula  (Fig. 
227)  will  be  required. 


COLLECTING   DISCHARGES   AND    SECRETIONS 


239 


The  pipettes  may  be  easily  made  from  thin  glass  tubing  of  an  ex- 
ternal diameter  of  about  i/ 4  inch  (6  mm.).  The  center  of  a  piece  of 
such  tubing  about  6  inches  (15  cm.)  long  is  heated  over  a  flame,  the 


Fig.  227. — Apparatus  for  collecting  discharges  for  bacteriological  examination 
I,  Alcohol  lamp;  2,  scissors;  3,  suction  syringe;  4,  pipettes. 

tube  continually  being  turned  the  while,  until  the  glass  is  softened 
over  about  1/2  inch  (i  cm.)  of  space  (Fig.  228).  The  tubing  is  then 
removed  from  the  flame,  and,  while  the  glass  is  still  soft,  the  two  ends 
are  drawn  apart  so  that  the  softened  central  portion  is  stretched  out 


Fig.  228. — Heating  the  glass  tube  at  its  center  over  a  Bunsen  flame.     (Ashton.) 

into  a  capillar}-  tube  several  inches  long  (Fig.  229).  The  center  of 
this  capillary  tube  is  again  heated  in  the  flame  until  it  melts,  and,  by 
drav-ing  upon  the  ends,  it  parts  in  the  center,  leaving  two  pipettes, 


240 


COLLECTION    OF    PATHOLOGICAL    MATERIAL 


each  with  one  sealed  end  (Fig.  230).  The  center  of  the  thick  por- 
tions of  each  of  these  pipettes  is  then  melted  in  the  same  way  and  is 
drawn  out  into  a  capillary  tube  an  inch  (2.5  cm.)  or  more  long,  so 


Fig.  229.^ — The  glass  tube  is  shown  drawn  out  at  its  center.      (Ashton.) 

that  we  have  as  a  result  two  pipettes  each  drawn  to  a  point  at  one  end, 
wide  at  the  other,  and  between  the  two  ends  a  bulb  separated  from 
the  wide  end  by  a  capillary  constriction  (Fig.  231).     The  pipettes  are 


Fig.  230. — Fusing  apart  the  center  of  the  drawn-out  portion  of  the  tube.     (Ashton.) 

sterilized,  after  inserting  a  piece  of  cotton  wool  in  the  wide  ends,  by 
passing  the  whole  tube  through  the  flame  until  it  is  hot  (Fig.  232), 
but  not  so  hot  as  to  melt  the  glass  or  burn  the  cotton  plug.     Thus 


Fig.  231. — Making  a  bulbous  pipette  by  heating  the  thick  portion  and  drawing  it 
out  to  a  thin  tube.      (Ashton.) 

sterilized,  the  pipettes  may  be  kept  on  hand  ready  for  use  almost 
indefinitely. 

The  suction  for  drawing  up  secretions  into  the  pipettes  may  be 


Fig.  232. — Sterilizing  the  interior  of  the  bulbous  portion  (b)  and  the  slender  end 
(a)   of  the  pipette;   (d)  plug  of  cotton.      (Ashton.) 

furnished  by  the  bulb  of  a  medicine  dropper,  or  by  attaching  a  piece 
of  rubber  tubing  to  the  pipette  and  applying  the  lips  or  a  small  suc- 
tion syringe  to  the  free  end  of  the  rubber  tubing. 


COLLECTING  DISCHARGES   AND    SECRETIONS 


241 


Technic. — The  pipettes  are  arranged  near  at  hand  upon  a  towel, 
and  the  alcohol  lamp  is  lighted.  The  sealed  end  of  the  pipette  should 
be  cut  off  with  scissors  (Fig.  233)  and  should  be  then  rounded  off 


Fig.  233. — Snipping  off  the  fused  point  of  the  slender  end  (a)  of  the  pipette  with 

scissors.     (Ashton.) 


Fig.  234. — Rounding  off  the  rough  edges  of  the  glass  in  the  flame.     (Ashton.) 

smooth  in  the  flame,  so  as  to  avoid  producing  any  injury  to  the  tissue 
(Fig.  234). 

The  pipette  is  then  slowly  passed   through   the   flame  so  as 


Fig.  235. — Sterilizing  the  outer  surface  of  the  slender  end  (a)  of  the  pipette. 

(Ashton.) 


Fig.  236. — Hermetically  sealing  the  secretions  in  the  bulbous  portion  of  the  pipette 
by  fusing  it  in  the  flame  at  a  and  c.     (Ashton.) 

to  sterilize  the  entire  outer  surface  of  the  tube  (Fig.  235).     When 
the  tube  has  cooled,  the  rubber  nipple  or  tubing  is  placed  upon  the 
large  end,  and  the  small  end  is  inserted  in  the  discharge  or  secretion. 
16 


242 


COLLECTION    OF   PATHOLOGICAL   MATERIAL 


which  is  then  drawn  up  into  the  pipette  by  suction.  The  suction  bulb 
is  then  removed,  and  the  small  end  of  the  pipette  is  sealed  by  melting 
it  in  the  flame.  The  constricted  portion  is  likewise  melted  in  the 
flame,  and  the  portion  of  the  pipette  containing  the  cotton  wool  is 
removed,  and  the  remaining  end  of  the  pipette  is  sealed  (Fig.  236). 
In  this  way  the  discharge  is  hermetically  sealed  in  small  glass  tubes 
(Fig.  237)  and  can  be  sent  to  any  distance  for  later  bacteriological 


Fig.  237. 


-Showing  the  bulbous  portion  of  the  pipette  sealed  and  containing  the 
secretion.      (Ashton.) 


examination.     Each  tube  as  it  is  prepared  should  be  carefully  labeled 
with  a  distinguishing  number. 

From  an  Abscess  Cavity. — Care  must  be  taken  that  no  anti- 
septic irrigating  fluid  is  used  before  the  discharge  is  secured.  A 
specimen  should  be  obtained  free  from  blood,  if  possible.  To 
avoid  contamination,  the  first  portion  of  the  pus  should  be  allowed 


Fig.  238. — Instruments  for  obtaining  secretions  from  the  nose  for  bacteriological 
examination,  i,  Sterile  angular  pipette;  2,  alcohol  lamp;  3,  scissors;  4,  nasal 
speculum;  5,  head  mirror. 

to  escape;  the  edges  of  the  incision  are  then  separated  while  the 
pipette  is  inserted  into  the  cavity,  and  a  specimen  is  withdrawn 
from  its  depths. 

From  Serous  Cavities. — The  method  of  obtaining  fluid 
from  serous  cavities  is  described  under  exploratory  punctures  (Chap- 
ter XI). 


COLLECTING    DISCHARGES    AND    SECRETIONS 


243 


From  the  Nose  and  Accessory  Sinuses. — Equipment. — An 

angular  pipette  will  be  required,  as  well  as  an  alcohol  lamp,  scissors,  a 
nasal  speculum,  suitable  illumination,  and  a  head  mirror  (Fig.  238). 

The  angular  pipette  may  be  made  by  taking  a  straight  pipette 
■with  a  long  capillary  tube,  heating  the  latter  at  a  distance  of  about 
3  inches  (7.5  cm.)  from  its  extremity  and,  when  soft,  bending  it  to 
an  angle  of  135  degrees.  The  end  should  be  well  smoothed  off  in  a 
flame  before  using. 

Technic. — The  same  general  principles  as  outlined  above  are 
foUowed.  The  patient  is  seated  as  for  an  anterior  rhinoscopic  exami- 
nation (page  312),  the  nasal  speculum  is  introduced,  and  the  light  is 


Fig.  239. — Method  of  sucking  secretion  into  a  pipette  from  the  female  urethra 

(Ashton.) 


reflected  so  that  the  interior  of  the  nose  can  be  clearly  observed. 
The  tip  of  the  pipette  is  then  inserted  until  it  comes  in  contact  with 
the  discharge,  care  being  taken  not  to  have  it  touch  the  mucous  mem- 
brane or  the  vibrissas  about  the  vestibule.  The  point  of  the  instrument 
is  moved  about  in  the  secretion  while  suction  is  exerted  and  some  of 
the  discharge  will  thus  be  withdrawn.  The  pipette  is  then  removed, 
sealed,  and  properly  labeled. 

From  the  Eyes. — The  technic  is  not  different  from  that  already 
described  for  collecting  discharges  from  other  regions,  and  no  special 
forms  of  pipettes  are  necessary.  Any  preliminary  cleansing  of  the 
eyes  should,  of  course,  be  avoided. 


244 


COLLECTION   OF   PATHOLOGICAL   MATERIAL 


From  the  Urethra. — Equipment. — Pipettes  and  the  other  ap- 
paratus necessary  for  collecting  discharges  (see  Fig.  227)  will  be 
required. 

Technic. — The  urine  should  not  be  voided  for  several  hours  prior 
to  obtaining  the  specimen.  The  urinary  meatus  is  first  exposed, 
and,  after  the  end  of  the  pipette  has  been  inserted  into  the  canal,  the 
secretion  is  sucked  into  the  pipette  (Fig.  239).  When  the  discharge 
is  scanty,  sufficient  may  be  obtained  by  expressing  the  pus  from  the 
posterior  portion  of  the  urethra  by  drawing  the  finger  along  the 
urethra  from  behind  forward.  In  the  female  the  same  method  may 
be  employed  with  the  index  finger  in  the  vagina  (see  Fig.  217). 
When  a  specimen  has  been  obtained,  the  ends  of  the  pipette  are 
sealed  and  the  tube  is  properly  labeled. 


Fig.  240. — Instruments  for  obtaining  secretions  from  the  vagina  for  bacterio- 
logical examination.  I,  Alcohol  lamp;  2,  scissors;  3,  suction  syringe;  4,  sterile 
pipettes ;  5,  vaginal  speculum. 

From  the  Vagina. — Equipment. — Pipettes,  a  suction  syringe 
and  rubber  tubing,  scissors,  an  alcohol  lamp,  and  a  vaginal  speculum 
(Fig.  240)  will  be  required. 

Technic. — The  labia  are  separated  and  the  speculum  is  introduced 
into  the  vagina,  so  that  the  posterior  cul-de-sac  is  exposed  to  view. 
The  distal  end  of  the  pipette  is  then  carefully  introduced  into  the  dis- 
charge, and  sufficient  secretion  for  the  purposes  of  the  examination  is 
withdrawn  by  means  of  suction.  The  pipette  is  then  removed, 
both  ends  are  sealed,  and  the  specimen  is  properly  labeled. 

From  the  Uterus. — Equipment. — Pipettes,  a  suction  syringe 
and  rubber  tubing,  scissors,  an  alcohol  lamp,  vaginal  specula,  two 
tenacula,  and  sponge  holders  (Fig.  241)  will  be  required. 


COLLECTION    OF  BLOOD    FOR   MICROSCOPICAL   EXAMINATION     245 

Technic. — The  speculum  is  introduced  into  the  vagina  and  the 
cervix  is  well  exposed  to  view.  Any  vaginal  secretions  are  removed 
by  means  of  sponges  on  holders,  tenacula  are  inserted  in  the  anterior 
and  posterior  lips  of  the  cervix,  and  the  latter  is  drawn  well  down. 
The  pipette  is  then  inserted  into  the  cervical  canal,  care  being  taken 
not  to  push  it  into  the  uterus,  and  the  secretion  is  sucked  into  it. 
It  is  then  withdrawn,  and  both  ends  are  sealed. 


Fig.  241. — Instruments  for  collecting  discharges  from  the  uterus  for  bacterio- 
logical examination.  (Ashton.)  i,  Pipettes;  2,  suction  syringe;  3,  Simon's 
speculum;  4,  tenacula;  5,  scissors;  6,  sponge  holder;  7,  alcohol  lamp. 


COLLECTION  OF  BLOOD  FOR   MICROSCOPICAL 
EXAMINATION 

Blood  may  be  examined  microscopically  either  from  a  fresh 
specimen  or  from  a  dried  smear.  The  former  procedure  is  suitable 
only  when  the  blood  can  be  examined  promptly — say  within  half  an 
hour.  A  smear  is  made  when  the  morphology  of  the  cellular  ele- 
ments is  to  be  studied  after  being  properly  stained. 

Equipment. — Slides,  cover-glasses,  an  alcohol  lamp,  thumb  for- 
ceps, and  a  spear-pointed  needle  or  a  lancet  (Fig.  242)  are  necessary. 
The  cover-glasses  and  slides  should  be  of  the  best  material.  The 
former  should  be  very  thin  and  about  7/8  inch  (22  mm.)  square. 
Both  should  be  absolutely  clean  and  free  from  grease;  the  cleansing 
may  be  performed  after  the  method  described  on  page  227. 

Location  of  Puncture. — The  blood  may  be  withdrawn  from  a 
prick  in  the  lobe  of  the  ear  or  in  the  tip  of  the  finger.  The  former 
region  is  preferable,  however,  as  it  is  not  so  sensitive  as  the  finger, 


246 


COLLECTION   OF   PATHOLOGICAL   MATERIAL 


and  it  is  usually  cleaner,  so  that  the  chances  of  infection  are  less. 
Furthermore,  when  the  puncture  is  made  in  the  ear,  the  operation  is 
removed  from  the  view  of  the  patient,  which  is  an  important  con- 
sideration in  the  case  of  children  and  nervous  individuals. 


\ 

\ 

3 


Fig.  242. — Instruments  for  collecting  blood  for  microscopical  examination. 
I,  Thumb  forceps;  2,  spear-pointed  needle;  3,  cover-glasses;  4,  glass  slides;  5. 
alcohol  lamp. 

Asepsis. — The  site  of  puncture  should  be  cleaned  by  first  rubbing 
it  with  a  wipe  wet  with  alcohol,  and  then  drying  it  with  ether.  The 
needle  or  lancet  is  sterilized  by  boiling  or  passing  it  through  a 
flame. 


Fig.  243. — Making  a  fresh  blood  smear.     First  step,  puncturing  the  ear. 

Technic. — i.  Fresh  Specimen. — Care  should  be  taken  to  avoid 
chilling  the  specimen  and  exposing  it  to  the  air  any  longer  than  is 
necessary;  accordingly,  everything  should  be  in  readiness  for  the 


COLLECTION    OF   BLOOD   FOE.   MICROSCOPICAL   EXAMINATION     247 

examination.  The  slide  is  warmed  over  the  alcohol  lamp  or  by 
vigorously  rubbing  it  with  a  piece  of  linen,  and  is  then  laid  on  a 
sterile  towel.  The  cover-glass  is  likewise  warmed  and  placed  near  at 
hand.  The  lobe  of  the  ear  is  grasped  between  the  thumb  and  fore- 
finger of  the  left  hand  and  with  a  quick  stab  the  lowest  portion  of  the 


Fig.  244. — Alaking  a  fresh  blood  smear.     Second  step,  collecting  the  drop  on  a 

cover-glass. 

lobe  is  punctured  (Fig.  243).  The  blood  should  be  allowed  to  flow 
■without  pressure  or  rubbing,  as  these  maneuvers  produce  a  hyperemia 
and  the  constituents  of  the  blood  may  be  changed  in  character  or 
the  blood  cells  may  be  deformed.     The  first  drop  is  wiped  away 


Pig.  245. — Making  a  fresh  blood   smear.     Third  step,   placing   the    cover-glass 
holding  the  blood  drop  on  a  slide. 

and  a  second  drop  is  allowed  to  flow.  The  cover-glass  is  then  taken 
up  in  the  thumb  forceps  and  is  applied  by  its  under  surface  to  the 
apex  of  the  drop  (Fig.  244),  but  is  not  allowed  to  touch  the  skin. 
The  cover-glass  is  then  gently  lowered  upon  the  w^armed  slide  (Fig. 
245)  and  the  drop  of  blood  is  thus  caused  to  spread  out  in  a  thin 


248 


COLLECTION    OF   PATHOLOGICAL   MATERIAL 


circular  layer  between  the  slide  and  the  cover-glass.  If  the  drop  is 
not  too  large,  the  blood  will  not  spread  beyond  the  margins  of  the 
cover-glass.  The  cover-glass  should  not  be  pressed  down  upon  the 
slide,  as  this  will  injure  the  corpuscles. 

2.  Dried  Specimen. — A  puncture  is  made  in  the  lobe  of  the  ear 


Fig.  246. — Method  of  making  a  drj'  blood  smear  with  two  slides. 

in  the  manner  described  above,  and,  after  the  first  drop  of  blood  has 
been  wiped  away,  the  second  drop  is  received  upon  a  slide  near  one 
end.  As  quickly  as  possible  the  edge  of  another  slide  is  dipped 
into  the  drop  thus  collected  and  is  drawn  along  the  surface  of  the 


Fig.  247. — Making  a  dry  blood   smear   with  two  cover-glasses.     Second  step, 
collecting  the  drop  on  a  cover-glass. 

first  slide,  spreading  out  the  drop  in  a  broad  thin  smear  (Fig.  246). 
To  be  of  any  value  the  smear  must  be  spread  out  evenly  and  thinly. 
A  second  method  is  to  employ  cover-glasses.  Two  cover-glasses 
are  thoroughly  cleansed  and  are  placed  conveniently  at  hand.  The 
ear  is  punctured  in  the  way  described  above  (see  Fig.  243),  and  the 


COLLECTION  OF  BLOOD   FOR   MLRCOSCOPICAL  EXAMINATION      249 

first  drop  of  blood  is  removed.  One  cover-glass  is  then  held  by  its 
sides  between  the  thumb  and  forefinger  of  the  right  hand,  while  the 
second  one  is  grasped  by  its  sharp  angles  in  the  fingers  of  the  left 
hand.  The  under  surface  of  the  first  cover  is  then  applied  to  the  apex 
of  the  drop  of  blood  (Fig.  247),  and  is  quickly  placed  upon  the  second 


Fig.  248. — Making  a  dry  blood  smear  with  two  cover-glasses.  Third  step,  the 
method  of  holding  the  two  cover-glasses  preparatory  to  placing  the  one  holding  the 
drop  upon  the  second  one. 


Pig.  249. — Making  a  dry  blood  smear  with  two  cover-glasses.  Fourth  step , 
showing  the  two  covers  with  their  surfaces  in  contact  and  the  drop  of  blood  spread 
out  in  a  thin  layer  between  them. 


Fig,  250. — Making  a  dry  blood  smear  with  two  cover-glasses.     Fifth  step,  showing 
the  method  of  drawing  the  two  covers  apart. 

glass,  with  the  angles  of  the  two  not  coinciding  (Fig.  248),  so  that  the 
drop  spreads  out  by  its  own  weight  in  a  thin  film  between  the  two 
covers  (Fig.  249).  If  too  large  a  drop  is  taken,  the  upper  cover  will 
simply  float  around  upon  the  lower.     The  upper  cover  is  finally 


2^0 


COLLECTION    Or    PATHOLOGICAL    MATERIAL 


seized  between  the  thumb  and  forefinger  of  the  right  hand  and,  still 
holding  the  lower  cover  in  the  left  hand,  the  two  covers  are  shd  apart 
in  the  same  plane  (Fig.  250).  Unless  too  small  a  drop  has  been 
taken,  this  is  readily  accomplished.  The  films  thus  obtained  are  then 
allowed  to  dry,  and  later  they  may  be  fLxed  and  properly  stained.  It 
is  always  well  to  make  three  or  four  of  these  smears,  as  some  of  the 
films  may  be  poorly  spread,  or  may  be  broken  in  handling. 

THE  COLLECTION  OF  BLOOD  FOR  BACTERIOLOGICAL 
EXAMINATION 

The  best  method  of  securing  blood  for  culture  is  by  a  venous  punc- 
ture. The  ordinary  method  of  obtaining  blood  through  a  prick  of 
the  ear  or  of  the  finger  is  worthless  for  bacteriological  purposes  on  ac- 
count of  the  small  amount  of  blood  obtained  and  the  chances  of  con- 
tamination, especially  from  the  skin.  If  properly  performed,  a  venous 
puncture  is  harmless  and  gives  the  patient  but  little  discomfort. 


%2^ 
Fig.  251. — Apparatus  for  collecting  blood  for  bacteriological  examination. 

Equipment. — A  glass  syringe  with  a  capacity  of  2  1/2  drams 
(about  10  c.c),  a  moderately  large  needle  with  a  sharp  point,  broth 
and  agar-agar  culture  tube,  and  a  bandage  (Fig.  251)  are  necessary. 

Site  of  Puncture. — The  median  cephalic  or  median  basilic  vein  is 
usually  chosen  (see  Fig.  114),  but,  if  these  are  not  available,  the  inter- 
nal saphenous  vein  in  the  leg  or  any  of  the  smaller  veins  about  the 
wrist  may  be  made  use  of. 

Asepsis. — The  skin  at  the  site  of  puncture  is  painted  with  iodin, 
the  hands  of  the  operator  are  as  carefully  sterilized  as  for  any 
operation,  and  the  instruments  are  boiled. 


COLLECTION    OF  BLOOD   FOR  BACTERIOLOGICAL   EXAMINATION  25 1 

Anesthesia. — In  ordinary  cases  anethesia  is  unnecessary.  If  it 
is  necessary  to  expose  the  vein  by  an  incision,  as  in  the  case  of  an 
individual  with  much  fat  or  whose  tissues  are  edematous,  infiltration 
with  a  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  novocain 
solution  is  employed. 

Technic. — A  bandage  is  wound  about  the  arm  between  the  seat  of 
puncture  and  the  heart  with  sufficient  tension  to  produce  a  slight 
venous  stasis  and  cause  the  veins  to  stand  out  prominently,  but  with 
not  enough  compression  to  cut  off  the  arterial  flow.  By  gently  forc- 
ing the  blood  along  toward  the  seat  of  constriction  by  means  of  the 
forefinger  or  thumb,  the  vein  may  be  made  to  stand  out  more  promi- 
nently. In  stout  persons,  however,  it  may  be  necessary  to  expose 
the  vein  by  an  incision. 

The  needle  with  the  syringe  attached  is  then  passed  obliquely 


Fig.  252. — Showing  the  method  of  making  a  venous  puncture. 

through  the  skin  into  the  vein  (Fig.  252),  and  the  blood  is  gently 
sucked  into  the  syringe  by  slowly  withdrawing  the  piston.  If  too 
great  an  amount  of  suction  is  exerted  the  wall  of  the  vein  will  be 
forcibly  collapsed  and  will  act  as  a  valve  against  the  further  with- 
drawal of  blood.  About  i  1/4  drams  (5  c.c.)  of  blood  may  be  taken 
from  a  child,  and  about  2  1/2  drams  (10  c.c.)  from  an  adult.  The 
needle  is  then  withdrawn,  the  constriction  being  first  removed  from 
the  arm  to  avoid  subcutaneous  hemorrhage  from  the  punctured  vein. 
Moderate  pressure  should  be  made  over  the  site  of  puncture  by  a 
piece  of  gauze  held  in  place  by  the  patient  or  by  an  assistant  while 
the  culture  tubes  are  being  inoculated.  This  inoculation  should  be 
done  immediately  and  before  the  blood  has  time  to  clot  in  the 
syringe. 

During  the  inoculation  of  the  tubes  the  greatest  care  should  be 


252 


COLLECTION    OF    PATHOLOGICAL   MATERIAL 


taken  to  avoid  contamination;  the  needle  is  removed  from  the  syringe' 
as  it  is  very  apt  to  be  contaminated  with  staphylococci  from  the 
skin,  no  matter  how  carefully  the  sterilization  may  have  been  carried 
out,  and  the  inoculation  is  made  through  the  sterile  end  of  the 
syringe.  In  doing  this,  the  same  technic  described  on  page  236  should 
be  followed.  Inoculations  are  usually  made  with  i6Tn,  (i  c.c.)  of 
blood  into  definite  quantities  of  media.  At  the  completion  of  the 
operation  the  seat  of  puncture  is  sealed  with  collodion. 


THE  COLLECTION  OF  SPUTUM 

Sputum  should  be  collected  in  absolutely  clean  wide-mouth 
ounce  (30  c.c.)  glass  bottles,  provided  with  a  water-tight  cork 
(Fig.  253),  so  that  there  can  be  no  leakage  during  transportation. 
Suitable  bottles  may  be  obtained  from  any  laboratory 
or  from  most  drug  stores.  The  specimen  should  be 
obtained  from  the  sputum  coughed  up  early  in  the 
morning  before  any  food  has  been  taken,  and  it  should 
be  seen  that  the  material  is  coughed  up  from  the  lungs 
and  that  it  is  not  simply  an  accumulation  from  the 
mouth  and  pharynx.  As  an  added  precaution  against 
contamination  from  particles  of  food,  tobacco,  vomitus, 
etc.,  the  mouth  and  pharynx  should  first  be  thoroughly 
rinsed  out.  When  there  is  not  sufficient  sputum  from 
one  collection,  the  whole  amount  for  the  day,  or  for 
twenty-four  hours,  should  be  preserved.  The  specimen 
thus  collected  should  be  sent  to  the  laboratory  promptly,  that  it 
may  be  examined  in  as  fresh  a  condition  as  possible. 

In  the  case  of  infants  and  young  children  it  may  be  next  to  im- 
possible to  obtain  sputum  in  the  ordinary  way.  A  method  sometimes 
employed  is  to  pass  a  stomach  tube  into  the  esophagus  and  then 
examine  the  mucus  found  adhering  to  the  tube  upon  its  withdrawal. 
Holt  advises  {Archives  of  Internal  Medicine,  May  15,  19 10)  the  follow- 
ing method:  The  child  is  made  to  cough  by  irritating  the  pharynx 
with  a  bit  of  gauze  or  cotton  held  in  the  jaws  of  an  artery  clamp,  and 
any  secretion  which  is  brought  into  view  is  then  secured  on  this  swab. 


Fig.  253.— 
vSputum  bottle 


THE  COLLECTION  OF  URINE 

When  a  simple  chemical  examination  of  urine  is  called  for,  it  is 
only  necessary  to  collect  the  specimen  in  some  perfectly  clean  re- 
ceptacle, the  first  portion  as  it  comes  from  the  meatus  being  received 


THE    COLLECTION    OE    URINE 


253 


in  another  vessel  and  then  rejected;  but  if  a  culture  is  to  be  made,  the 
urine  must  be  obtained  by  catheter  under  rigid  asepsis.  The  catheter 
must  be  boiled  and  the  hands  of  the  operator  must  be  sterilized  as  for 
any  operation.  The  meatus  and  surrounding  parts  are  then  washed 
with  an  antiseptic  solution,  and  the  catheter  is  gently  inserted  into 
the  bladder  without  touching  the  adjacent  parts  (see  also  page  687). 
The  first  portion  of  the  urine  is  to  be  discarded,  and  then  from  i  1/4 
to  2  1/2  drams  (about  5  to  10  c.c.)  are  collected  in  a  sterile  test-tube, 
which  is  immediately  plugged. 

When  it  is  desired  to  obtain  a  separate  specimen  from  each  kidney, 
the  ureters  may  be  catheterized  (see  page  705)  or  a 
urinary  separator  maybe  employed  (see  page  721). 

To  obtain  a  twenty-four-hour  specimen,  as, 
for  example,  when  it  is  desired  to  determine  the 
total  daily  amount  of  urine  secreted  or  to  esti- 
mate the  total  solids,  it  is  necessary  to  begin  and 
end  with  an  empty  bladder.  The  patient  is  there- 
fore instructed  to  empty  the  bladder  at  a  certain 
hour  and  to  discard  this  specimen.  All  the  urine 
passed  for  the  following  twenty-four  hours,  includ- 
ing that  voided  at  the  end  of  this  period,  is  saved 
in  a  large  clean  bottle.  For  cases  of  incontinence, 
a  retained  catheter  must  be  used  (see  page  689), 
or  else  a  rubber  urinal  devised  for  such  cases  may 
be  employed. 

When  considerable  time  must  elapse  before  a 
specimen  can  be  examined,  some  preservative, 
such  as  boric  acid  in  the  proportion  of  i  grain 
(0.065  gm.)  to  each  ounce  (30  c.c),  formalin  in  the 
proportion  of  i  drop  to  each  4  ounces  (120  c.c),  or  a  few  drops  of 
chloroform  to  each  4  ounces  (120  c.c.)  may  be  added  to  the  speci- 
men. If  culutres  or  inoculations  are  to  be  made,  any  preservative 
should  be  avoided. 

In  the  case  of  infants  there  are  several  methods  for  collecting 
urine.  With  male  infants,  for  an  ordinary  examination,  the  specimen 
may  be  collected  by  means  of  a  condom  which  is  secured  to  the  body 
by  adhesive  plaster,  and  into  which  the  penis  and  scrotum  are  passed ; 
or  a  bottle  may  be  employed,  in  the  neck  of  which  the  penis  is  placed. 
Chapin  has  devised  a  urine  collector  (Fig.  254)  that  may  be  employed 
for  both  males  and  females.  A  method  sometimes  employed  with 
females  is  to  place  absorbent  cotton  over  the  vulva,  and,  after  the 


Fig.  254.-Chapin.'s 
urine  collector. 


254  COLLECTION    OF   PATHOLOGICAL   MATERIAL 

child  has  saturated  the  cotton,  to  express  the  urine  into  a  bottle;  or 
the  child  may  simply  be  placed  upon  a  rubber  sheet  from  which  the 
urine  is  collected  as  often  as  it  is  voided.  If  it  is  necessary  to  obtain 
an  uncontaminated  specimen,  catheterizfation  must  be  resorted  to, 
employing  a  small  catheter  (9  to  ii  French). 

THE  COLLECTION  OF  GASTRIC  CONTENTS 

For  a  microscopical  examination  of  the  stomach  contents  a  test 
meal  is  not  necessary,  the  vomitus  or  a  portion  removed  by  the 
stomach  tube  (see  page  476)  being  all  that  is  required.  The  specimen 
should  be  received  in  a  clean  glass  receptacle. 

For  a  complete  chemical  examination  and  to  test  the  condition  of 
the  stomach,  the  gastric  contents  an  hour  after  a  test-meal  will  be 
required  (see  page  475). 

THE  COLLECTION  OF  FECES 

Ordinarily  a  small  amount  should  be  received  in  a  sterilized 
wide-mouth  glass  jar  and  the  examination  made  as  soon  as  possible. 

When  examining  for  the  ameba,  it  becomes  necessary  to  collect 
the  stools  in  a  clean  warm  receptacle  and  to  make  the  examination 
immediately  upon  a  warmed  slide,  or  else  to  provide  some  means  for 
keeping  the  specimen  warm  until  the  examination  can  be  conveniently 
made. 

THE  REMOVAL  OF  A  FRAGMENT  OF  SOLID  TISSUE  FOR 

EXAMINATION 

The  excision  of  pieces  of  tissue  for  microscopical  examination 
may  be  required  in  cases  where  it  seems  probable  that  a  tumor  is 
malignant  but  where  the  clinical  signs  and  symptoms  are  not  pro- 
nounced enough  to  make  a  positive  diagnosis.  The  information  thus 
obtained  is  especially  valuable  in  growths  of  recent  development,  as 
in  these  the  evidence  of  malignancy  is  often  not  apparent  from  a 
gross  examination. 

Instruments.^ — In  ordinary  cases  there  will  be  required :  a  scalpel, 
scissors,  a  cutaneous  punch,  artery  clamps,  plain  thumb  forceps 
mouse-toothed  forceps,  small  sharp  retractors,  a  needle  holder.  No.  2 
catgut  sutures,  curved  needles  with  cutting-edges,  and  a  wide-mouth 
clean  bottle  provided  with  a  water-tight  cork  and  containing  a  4 
per  cent,  aqueous  solution  of  formalin  (Fig.  255). 

For  regions  which  are  not  readily  accessible,  as,  for  example,  the 


REMOVAL   OF   A   FRAGMENT   OF   TISSUE   FOR   EXAMINATION      255 


Fig.  255. — Instruments  for  excising  a  fragment  of  solid  tissue  for  examination. 
I,  Scalpel;  2,  curved  sharp-pointed  scissors;  3,  skin  punch;  4,  thumb  forceps;  5, 
artery  clamps;  6,  retractors;  7,  needle  holder;  8,  No.  2  catgut;  9,  curved  cutting- 
edge  needles;  10,  specimen  bottle. 


Fig.  256. — Excision  of  a  piece  of  tissue  from  the  cervix.      (Ashton.) 


2s6 


COLLECTION    OF   PATHOLOGICAL   MATERIAL 


female  genitals,  volsellum  forceps  and  suitable  specula  are  necessary. 

For  collecting  material  from  the  interior  of  the  uterus,  curettage 
instruments,  etc.,  will  be  required  (see  page  808). 

Anesthesia. — As  a  rule,  local  anesthesia  by  infiltration  with   a 


Fig.  257. — Removal  of  a  fragment  of  a  superficial  growth  with  a  skin  punch. 

0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  solution  of  novocain 
in  normal  salt  solution  is  sufficient.  For  skin  tumors,  freezing  with 
ethyl  chlorid  usually  suffices. 


^^^^^^^ 


Fig.  258. — Removal  of  a  fragment  of  a  superficial  growth  with  a  skin  punch- 
Second  step,  cutting  loose  the  base  of  the  section. 

Asepsis. — The  instruments  are  boiled,  the  hands  of  the  operator 
are  sterilized,  and  the  site  of  operation  is  cleaned  as  for  any  operation. 

Technic. — The  fine  of  proposed  incision  is  first  anesthetized. 
Then,  with  the  tissues  well  retracted  so  as  to  expose  the  growth,  a 


REMOVAL   OF   A   FRAGMENT   OF   TISSUE   FOR   EXAMINATION      257 

wedge-shaped  piece  of  tissue  is  removed  by  means  of  a  scalpel  from 
the  portion  of  the  growth  where  the  pathological  changes  are  most 
marked  or  the  tumor  is  nodular  (Fig.  256).  The  tissue  is  then  trans- 
ferred to  the  bottle  containing  the  4  per  cent,  formalin  solution,  and  a 
proper  label  is  applied.  Any  hemorrhage  is  then  controlled,  the 
incision  is  closed,  and  a  sterile  dressing  is  finally  applied. 

A  fragment  of  a  very  superficial  tumor  or  of  a  skin  growth  may  be 
removed  by  means  of  a  punch  if  desired.  The  skin  is  frozen  with 
ethyl  chlorid,  and  by  a  rotary  motion  the  punch  is  made  to  cut  out  a 
circular  piece  of  tissue  (Fig.  257),  The  punch  is  then  removed  and 
the  circular  core  is  seized  in  thumb  forceps  and  is  freed  from  its 
base  by  cutting  with  a  pair  of  curved  scissors  (Fig.  258).  The  punch 
may  be  employed  in  the  same  way,  if  desired,  for  removal  of  deeper 
seated  growths  after  first  exposing  the  tumor  by  an  incision. 

When  tissue  is  removed  by  curettage  for  examination,  the  uterus 
should  be  scraped  systematically,  and,  as  soon  as  collected,  the  frag- 
ments thus  obtained  should  be  placed  in  a  bottle  containing  the 
preserving  fluid.  The  bottle  is  then  carefully  labeled.  Care  should 
be  taken  to  avoid  rough  handling  of  the  tissues  and  to  preserve  for 
examination  all  the  fragments  removed.  For  the  technic  of  curettage 
see  page  809. 


17 


CHAPTER  XT 
EXPLORATORY  PUNCTURES 

An  exploratory  puncture  consists  in  the  introduction  of  a  hollow 
needle  attached  to  an  aspirating  syringe  into  a  diseased  region,  and  a 
subsequent  aspiration.  This  comparatively  simple  operation  may 
be  performed  for  the  purpose  of  determining  the  presence  or  absence 
of  fluid  in  any  particular  area,  or  to  obtain  a  specimen  of  fluid  for 
the  purpose  of  determining  its  character  by  subsequent  examination. 
In  addition,  exploratory  punctures  are  made  prior  to  therapeutic 
punctures  to  determine  the  exact  location  of  the  fluid  to  be  evacuated. 
In  deeply  seated  processes,  as  suppuration  and  fluctuating  tumors, 
inaccessible  to  other  means  of  diagnosis,  this  method  of  exploration 
often  gives  most  valuable  information.  The  liver,  the  lungs,  the 
pleural  and  pericardial  cavities,  the  spinal  canal,  and  other  organs 
and  regions  difficult  of  access  may  thus  be  tapped  and  explored  with 
comparative  safety. 

Whenever  fluid  is  detected  a  quantity  suflScient  for  examination 
should  be  withdrawn.  Frequently  by  a  gross  examination  of  the 
fluid  sufficient  information  may  be  obtained  as  to  its  character. 
With  the  naked  eye.  one  can  often  make  a  diagnosis  between  a  serous, 
bloody,  or  purulent  fluid,  by  carefully  noting  the  color,  clearness,  and 
consistency  of  the  material  withdrawn.  \'aluable  information  can 
likewise  be  obtained  from  the  odor. 

For  more  definite  and  exact  information,  a  chemical,  microscopi- 
cal, and  bacteriological  examination  will  be  necessary.  In  prepara- 
tion for  such  an  examination  a  few  drops  of  the  Hquid  should  be 
injected  into  culture  tubes,  and  the  remainder  placed  in  a  sterilized 
test-tube,  previously  provided,  and  kept  in  readiness  for  this  purpose. 
At  times  the  aspirated  fluid  may  be  so  thick  that  only  a  few  flakes  or 
floccules  of  purulent  matter  can  be  obtained.  Such  material,  or  any 
fragments  of  tissue  adhering  to  the  needle  point  should  be  carefully 
transferred  to  a  glass  slide  for  later  microscopical  examination. 
Even  specimens  from  solid  growths  large  enough  for  microscopical 
examination  may  at  times  be  obtained  by  rotating  the  needle  and 
moving  it  back  and  forth  sufficiently  to  detach  a  small  fragment, 
which  may  then  be  secured  by  producing  a  strong  vacuum  in  the 
syringe  and  very  carefully  withdrawing  the  needle. 


EXPLORATORY    PUNCTURE    OF    THE    PLEURA  259 

The  laboratory  examination  of  the  fluid,  the  technic  of  which  may 
be  found  fully  described  in  manuals  on  clinical  laboratory  methods, 
should  be  made  along  the  following  lines  and  with  reference  to  the 
special  points  mentioned. 

1.  Physical  Characteristics. — The  color,  odor,  clearness,  consist- 
ency, reaction,  coagulability  and  specific  gravity  of  the  fluid,  and 
the  character  of  the  sediment  should  be  noted. 

2.  Chemical  examination  should  include  tests  for  albumin,  serum 
globulin,  sugar,  bile,  urea,  blood,  pus,  etc, 

3.  Microscopical  examination  is  made  for  the  purpose  of  detecting 
the  presence  of  blood-corpuscles,  epithelial  cells,  hematoidin  and 
cholesterin  crystals,  specific  tumor  cells  or  fragments,  necrotic  tissue, 
ameba,  hydatid  booklets,  ray  fungi,  etc. 

4.  Bacteriological  Examination. — Smear  preparations  are  made 
and  examined  for  pathogenic  bacteria,  while  organisms  susceptible 
of  culture  are  inoculated  upon  suitable  media  and  later  examined 
microscopically.  Thus  organisms  may  be  identified  which  are  not 
readily  detected  by  direct  examination. 

5.  Cytodiagnosis. — By  this  is  understood  the  determination  of 
the  cause  of  an  effusion  from  the  relative  number  and  the  character 
of  its  cellular  constituents. 

EXPLORATORY  PUNCTURE  OF  THE  PLEURA 

This  is  a  safe  and  simple  operation  employed  to  confirm  the 
diagnosis  of  a  pleural  eft'usion  or  to  ascertain  the  nature  of  the  fluid. 
The  danger  of  injuring  the  lung  and  producing  a  pneumothorax  need 
not  be  considered  if  reasonable  care  be  observed  in  performing  the 
puncture. 

Apparatus. — Aspirating  needles  and  a  syringe  of  appropriate  size 
should  be  provided.  It  Avill  be  found  convenient  to  have  an  assort- 
ment of  needles  of  difl'erent  lengths  and  diameters.  They  should 
measure  in  length  2  1/2  inches  (6.5  cm.),  3  inches  (7.5  cm.),  31/2 
inches  (9  cm.),  and  4  inches  (10  cm.);  and  in  diameter  1/50  inch  (0.5 
mm.),  1/25  inch  (i  mm.),  1/18  inch  fi.5  mm.),  and  1/12  inch  (2 
mm,).  For  ordinary  use  the  needle  should  be  at  least  3  inches  (7.5 
cm.)  long  and  about  1/25  inch  (i  mm.)  in  diameter,  so  that  it  will 
readily  giv^e  passage  to  fluids  of  heavy  consistency. 

It  is  preferable  to  have  a  syringe  with  a  capacity  of  from  i  to  2 
drams  (4  to  8  c.c),  though  an  ordinary  hypodermic  syringe  may  be 
employed  if  the  large  needles  are  made  to  fit.     The  syringe  should  be 


26o 


EXPLORATORY  PUNCTURES 


capable  of  exerting  a  strong  suction,  and  the  joint  between  it  and  the 
needle  should  be  absolutely  air-tight.  The  best  form  of  syringe  con- 
sists of  a  solid  glass  barrel  and  a  tight-fitting  piston  provided  with  an 
asbestos  or  rubber  packing  (Fig.  259).  Such  a  syringe  is  simple  in 
mechanism,  easy  to  clean,  and  can  be  readily  sterilized  by  boiling. 
If  confirmation  of  the  diagnosis  of  fluid  is  to  be  immediately  followed 


Fig.  259. — Aspirating  syringe  and  needles. 

by  its  evacuation,  the  aspirating  apparatus  of  Potain  or  Dieulafoy 
(see  page  286)  may  be  used  for  the  exploration,  thus  sparing  the 
patient  a  subsequent  operation. 

In  addition  there  should  be  provided  a  scalpel  and  a  cocain 
syringe  or  tube  of  ethyl  chlorid  for  anesthetizing  the  point  of  puncture. 

Before  making  a  puncture  the  syringe  should  always  be  tested 


\^ 


Pig,  260. — Apparatus  for  making  smears  and  cultures  from  fluids  removed  by 
exploratory  puncture,      i,  Glass  slides;  2,  sterile  test-tube;  3,  culture  tubes. 

by  withdrawing  the  piston  with  the  finger  held  over  the  end,  to  see  if 
it  will  exert  proper  suction.  The  syringe  should  likewise  be  tested 
with  the  needle  fitted  in  place.  After  use,  the  syringe  should  be 
taken  apart,  and  both  it  and  the  needle  should  be  thoroughly  cleansed. 
To  guard  against  rusting,  the  lumen  of  the  needle  should  be  cleansed 
with  alcohol  and  ether,  and  a  wire  of  suitable  size  inserted. 


EXPLOR-\TORY  PUNXTURE  OF  THE  PLEURA 


261 


In  cases  where  a  complete  chemical,  microscopical,  and  bac- 
teriological examination  is  desired,  sterilized  test-tabes  for  collecting 
and  transporting  the  material  aspirated,  glass  slides,  and  agar-agar 
culture  tubes  (Fig.  260)  should  be  at  hand. 

Location  of  the  Puncture.— No  fixed  rule  can  be  laid  down,  the 
point  chosen  for  the  puncture  depending  upon  the  physical  examina- 
tion. The  needle  should  enter  a  spot  where  there  is  dullness  and  an 
absence  of  respiratory  sounds,  voice,  and  fremitus,  and,  at  the  same 
time,  the  point  of  puncture  should  lie  well  below  the  upper  level  of 
the  effusion.     If  it  is  made  too  high,  the  point  of  the  needle  may 


Fig. 


261. — Showing  the  points  for  inserting  the  needle  in  exploratory  puncture  of 
the  pleura.      (Large  dots  represent  points  of  election.) 


lacerate  the  lung;  or,  if  too  low,  injury  to  the  diaphragm,  liver,  or 
spleen  may  result.  As  a  general  thing,  entrance  of  the  needle  in 
the  sixth  interspace  in  the  anterior  axillary  line,  in  the  sixth  or  seventh 
interspace  in  the  midaxillary  Une,  or  the  eighth  interspace  below 
the  angle  of  the  scapula  will  reveal  the  presence  of  fluid  if  such  exist 
(Fig.  261). 

Position  of  the  Patient. — If  too  weak  to  sit  upright,  the  patient 
may  He  semirecumbent  for  a  lateral  puncture,  and  for  a  posterior 
puncture  in  a  lateral  prone  position,  with  the  body  carved  forward 
and  the  arm  of  the  affected  side  elevated  (Fig.  262).  In  uncom- 
pHcated  cases,  an  upright  sitting  posture  should  be  assumed,  with  the 


262 


EXPLORATORY   PUNCTURES 


arm  of  the  affected  side  elevated  for  the  purpose  of  widening  the 
intercostal  spaces  (Fig.  263). 

Asepsis. — The  strictest  regard  to  asepsis  must  be  observed  in  mak- 


FiG.  262. — Lateral  position  for  exploratory  puncture  of  the  pleura. 


Fig.  263. — Exploratory  puncture  of  the  pleura  with  the  patient  sitting  upright. 

ing  any  exploratory  puncture,  otherwise  there  is  great  risk  of  in. 
fection  and  of  converting  a  simple  serous  exudate  into  a  purulent  one. 


EXPLORATORY    PUNXTURE    OF    THE    PLEURA 


263 


The  site  chosen  for  the  puncture  should  be  well  painted  with  tinc- 
ture of  iodin.  The  operator's  hands  should  also  be  thoroughly 
scrubbed,  followed  by  immersion  in  an  antiseptic  solution.  The 
needles,  svringes,  and  other  instruments  employed  are  sterilized 
by  boiling. 

Anesthesia. — ^Local  anesthesia  by  freezing  with  ethyl  chlorid  or 
salt  and  ice.  or  infiltrating  with  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain,  will  be  all  that  is  required. 
In  emplopng  cold  as  an  anesthetic,  if  the  patient  is  poorly  nourished 
or  the  skin  is  edematous,  care  should  be  taken  not  to  freeze  the  skin 
too  thoroughly,  on  account  of  the  danger  of  local  necrosis. 

Technic. — To  avoid  injury  to  the  upper  intercostal  artery  the 
needle  is  inserted  near  the  upper  margin  of  the  rib  which  forms  the 


Fig.  264.  Fig.  265. 

Fig.  264. — Showing  the  failure  to  withdraw  flmd  from  the  needle  being  inserted 
too  far.      (xAiter  Gumprecht.) 

Fig.  265. — Showing  the  failure  to  withdraw  fluid  from  the  needle  entering  the 
pleura  at  too  high  a  level.      (After  Gumprecht.) 

lower  boundary  of  the  space  chosen  for  the  puncture.  The  point  of 
puncture  is  anesthetized  and  a  small  nick  is  made  in  the  skin. 
The  thumb  and  forefinger  of  the  left  hand  steady  the  tissues,  while 
the  needle  is  slowly  and  steadily  inserted  upward  and  inward,  until 
its  point  enters  the  pleural  sac.  From  i  to  i  i^  2  inches  (about  2.5 
to  4  cm.)  under  ordinary  conditions,  and  more  in  fat  subjects  or  in 
those  with  very  thick  pleura,  may  be  estimated  as  the  thickness  of 
the  thoracic  wall  through  which  the  needle  will  have  to  pass  before 
entering  the  pleural  cavity.  The  lack  of  resistance  and  the  mobility 
of  the  needle  will  acquaint  one  of  its  entrance  into  a  ca\"ity. 

If  fluid  is  not  immediately  obtained,  the  direction  of  the  needle 
may  be  changed  slightly,  or  it  may  be  entirely  withdrawn  and  inserted 
in  other  locations  before   the  attempt  is   abandoned.     Failure  to 


264 


EXPLORATORY  PUNCTURES 


withdraw  fluid  may  be  due  to  the  needle  entering  the  lung  CFig.  265) 
or  to  the  fluid  being  encapsulated  in  a  space  not  entered  by  the 
aspirating  needle.  Again,  the  point  of  the  needle  may  become  buried 
in  adhesions  or  a  thickened  pleura  (Fig.  266),  or  its  caliber  may  be- 
come blocked  by  coagulated  material.  In  addition  to  determining 
the  presence  of  fluid,  any  unusual  thickness  or  density  of  the  pleura 
may  be  appreciated  by  the  operator  through  the  amount  of  resis- 
tance oft"ered  to  the  entrance  of  the  needle.  Upon  completion  of  the 
aspiration,  the  needle  is  quickly  withdrawn,  and  the  site  of  the 
puncture  is  closed  with  collodion  and  cotton. 


Fig.  266. — Showing  the  faikire  to'  withdraw  fluid -from  the  point  of  the  needle 
becoming  imbedded  in  a  thickened  pleura.      (After  Gumprecht.) 


EXPLORATORY  PUNCTURE  OF  THE  LUNG 

Previous  to  undertaking  any  operative  procedure  upon  a  pul- 
monary cavity,  such  as  a  tubercular,  bronchiectatic,  echinococcic,  or 
abscess  cavity,  an  exploratory  puncture  will  be  of  great  service,  not 
only  as  an  aid  to  a  physical  examination  in  detecting  such  a  cavity, 
but  likewise  in  determining  its  size  and  exact  location,  and  its 
character  by  an  examination  of  the  fluid  withdrawn. 

There  is  considerable  risk  of  infecting  the  pleura  or  of  producing 
a  cellulitis  if  aspiration  of  a  pulmonary  cavity  without  immediate 
drainage  be  performed,  hence  the  exploratory  puncture  should  only 
be  performed  on  the  operating-table  with  the  patient  ready  to  be 
anesthetized,  and  with  all  preparations  to  incise  and  drain  the  cavity 
completed  beforehand,  in  case  pus  is  obtained. 

Apparatus. — Exploring  needles  and  a  glass  aspirating  syringe,  a 
scalpel,  ethyl  chlorid  or  a  cocain  syringe,  test  tubes,  and  culture 
tubes  will  be  required  (see  page  259). 

Location  of  the  Puncture. — This  will  depend  entirely  upon  the 


EXPLORATORY   PUNCTURE    OP    THE    PERICARDIUM  265 

approximate  situation  of  the  cavity,  as  determined  by  the  physical 
signs. 

Asepsis. — The  instruments  should  be  boiled,  the  operator's  hands 
sterilized  as  for  any  operation,  and  the  site  of  puncture  painted  with 
iodin. 

Anesthesia. — Infiltration  of  the  site  of  puncture  with  a  0.2  per 
cent,  solution  of  cocain  or  a  i  per  cent,  novocain  solution,  or  freezing 
by  means  of  ethyl  chlorid  or  salt  and  ice  will  be  sufficient. 

Technic. — A  fair-sized  aspirating  needle,  at  least  4  inches  (10  cm.) 
long,  will  be  required.  The  point  of  puncture  is  anesthetized  and 
the  skin  is  nicked  with  the  point  of  a  scalpel.  Then,  while  the  patient 
holds  the  breath  to  limit  movement  of  the  lungs,  the  needle  is  in- 
serted in  the  direction  of  the  supposed  cavity,  close  to  the  upper 
margin  of  the  rib,  in  the  same  manner  as  already  described  for  ex- 
ploratory puncture  of  the  pleura  (page  263).  As  the  needle  is  slowly 
advanced,  attempts  to  withdraw  fluid  are  made  at  successive  depths. 
The  abscess  may  be  superficial,  and  even  adherent  to  the  chest  wall 
where  it  can  be  easily  reached,  but  more  often  it  will  be  necessary  to 
insert  the  needle  a  distance  of  3  to  4  inches  (7.5  to  10  cm.)  before  the 
cavity  is  entered.  Failing  to  withdraw  pus,  the  needle  should  be 
removed  and  reinserted  at  another  spot.  It  may  even  be  necessary 
to  make  a  number  of  punctures  before  being  successful,  as  the  locali- 
zation of  a  pulmonary  cavity  is  at  times  a  most  difficult  matter. 
When  a  needle  enters  a  cavity,  some  idea  of  its  size  may  be  obtained 
from  the  range  of  motion  of  the  needle  and  from  the  quantity  of 
secretion  withdrawn,  though,  if  there  has  been  considerable  expec- 
toration previous  to  the  puncture,  little  or  no  fluid  will  be  obtained, 
even  though  the  needle  enter  a  cavity. 

When  pus  is  obtained,  the  needle  should  be  left  in  place  as  a 
guide  for  the  incision  and  drainage,  and,  while  the  patient  is  being 
anesthetized,  great  care  should  be  taken  to  see  that  the  needle  is  not 
displaced. 

EXPLORATORY  PUNCTURE  OF  THE  PERICARDIUM 

An  exploratory  puncture  may  be  required  as  a  means  of  making  a 
positive  diagnosis  of  the  presence  of  fluid  within  the  pericardium  or 
for  the  purpose  of  choosing  a  route  through  which  such  fluid  may  be 
reached  and  evacuated.  Puncture  of  the  pericardium  should  not  be 
undertaken  lightly,  and  the  dangers  of  injuring  the  internal  mammary 
vessels  or  pleura,  or  of  puncturing  the  thin-walled  auricles  of  the 


266 


EXPLORATORY    PUNCTURES 


heart,  should  impress  upon  the  operator  the  necessity  of  extreme  care 
when  performing  this  operation. 

Apparatus. — A  fine  exploring  needle  and  a  glass  aspirating  syringe, 
a  scalpel,  ethyl  chlorid  or  a  cocain  syringe,  test  tubes,  and  culture 
tubes  will  be  required  (see  page  259). 

Location  of  the  Puncture. — To  eliminate  as  far  as  possible  the 
dangers  of  the  operation,  special  sites  for  puncture  have  been  rec- 
ommended, as  follows:  (i)  In  the  fourth  or  fifth  interspace,  either 
close  to  the  left  sternal  margin  or  i  inch  (2.5  cm.)  to  the  left  of  it. 
Either  of  these  points  will  avoid  the  internal  mammary  artery  and 


Fig.  267. — -Points  for  puncturing  the  pericardium.  The  dotted  line  indicates 
a  distended  pericardial  sac.  The  course  of  the  internal  mammarj'^  vessels  is  also 
shown. 


veins  which  run  vertically  downward  1/2  inch  (i  cm.)  from  the  ster- 
nal margin.  (2)  In  the  fifth  intercostal  space,  close  to  the  right  of 
the  sternum.  It  is  claimed  that  from  this  point  it  is  impossible  to 
injure  the  heart,  but  this  avenue  of  approach  is  only  suitable  when  the 
amount  of  fluid  is  large.  (3)  Inserting  the  needle  directly  upward 
and  backward  close  to  the  costal  margin  in  the  space  between  the 
ensiform  cartilage  and  the  seventh  costal  cartilage  on  the  left  side. 
(4)  When  it  is  possible  to  outline  accurately  the  shape  of  the  peri- 
cardium and  locate  the  position  of  the  apex  beat  by  means  of  pulsa- 
tion or   friction  rubs,    the   method   recommended   by    Curschman, 


EXPLORATORY    PU^'CTURE    OF    THE    PERICARDIUM  267 

Romberg,  Kussmaul,  and  others,  may  be  employed.  The  puncture 
is  made  in  the  hfth  or  sixth  left  interspace  outside  the  nipple  line 
between  the  apex  beat  and  the  outer  limit  of  dullness  (Fig.  267). 

The  selection  of  one  of  these  sites  over  the  others  will  be  made 
according  to  the  degree  of  distention  of  the  pericardium  and  its 
shape,  which  is  determined  by  outlining  the  area  of  dullness. 

Preparation  of  the  Patient. — If  the  patient  be  a  male,  the  chest 
should  be  shaved,  and,  in  any  case,  the  skin  must  be  steriHzed  thor- 
oughly before  making  the  puncture. 

Position  of  the  Patient. — The  operation  may  be  performed  with 
the  patient  semirecumbent  or  in  the  upright  sitting  posture. 


Fig.  268.- — Showing  the  method  of  inserting  the  needle  in  an  exploratory  puncture 

of  the  pericardium. 

Technic. — As  already  emphasized,  all  the  aseptic  precautions  enu- 
merated under  exploratory  punctures  (page  262)  should  be  carefully 
carried  out.  The  area  of  dullness  is  accurately  mapped  out  and  the 
point  for  puncture  thereby  determined  upon.  This  point  is  anes- 
thetized and  a  small  nick  is  made  in  the  skin.  The  thumb  of  the  left 
hand  is  placed  as  a  guide  upon  the  lower  rib  bounding  the  intercostal 
space  selected,  and  the  needle  point  is  inserted  just  above  the  margin 
of  the  rib  so  as  to  avoid  the  upper  intercostal  artery  (Fig.  268).  The 
needle  should  be  introduced  slowly  and  with  great  care  almost  in  the 
sagittal  plane  and  directed  slightly  toward  the  median  line.  En- 
trance into  the  pericardial  sac  is  suspected  when  resistance  to  the 
progress  of  the  needle  is  no  longer  encountered,  or  when  the  heart  is 
felt  striking  against  the  needle  point.     The  needle  should  not  be 


268  EXPLORATORY    PUNXTURES 

inserted  a  greater  distance  than  i  inch  (2.5  cm.),  and,  if  fluid  is  not 
reached  at  this  depth  from  one  location  the  other  points  of  entrance 
above  mentioned  may  be  employed.  Should  the  fluid  obtained  be 
purulent  in  character,  prompt  incision  and  drainage  is  indicated. 

When  the  purpose  of  the  puncture  is  accomplished,  the  needle  is 
slowly  withdrawn,  and  the  point  of  puncture  is  sealed  with  collodion 
and  cotton. 

EXPLORATORY  PUNCTURE  OF   THE  PERITONEAL  CAVITY 

Aspiration  of  small  quantities  of  peritoneal  fluid  and  examination 
of  the  specimen  obtained  may  be  required  to  determine  the  type  of  an 
effusion  into  the  peritoneal  cavity — whether  it  be  serous,  inflam- 
matory, hemorrhagic,  or  chylous.  Puncture  of  solid  or  fluctuating 
masses  within  the  abdomen  may  likewise  be  performed  as  a  diagnostic 
measure,  but  the  dangers  of  producing  serious  complications  through 
puncture  of  the  intestine  or  other  organs,  or  from  leakage  of  fluid, 
especiaUy  if  it  be  purulent,  into  the  peritoneal  cavity  stamps  it  as  an 
unsafe  method  except  in  those  cases  where  the  tumor  is  in  close  rela- 
tion to  the  abdominal  wall.  When  the  presence  of  pus  is  suspected, 
it  is  not  wise  to  perform  an  exploratory  puncture  unless  everything 
is  in  readiness  for  an  immediate  operation.  The  comparative  safety 
of  an  exploratory  laparotomy  and  the  fact  that  much  more  valu- 
able information  can  be  thus  obtained  render  this  the  operation  of 
choice. 

Apparatus. — A  long  exploring  needle,  a  glass  aspirating  syringe, 
a  scalpel,  a  cocaine  syringe,  test-tubes,  etc.,  should  be  provided  (see 
page  259). 

Location  of  the  Puncture. — For  puncture  of  the  peritoneal  cavity, 
a  point  midway  between  the  umbilicus  and  the  pubes  in  the  median 
line  or  a  point  at  the  junction  of  the  outer  and  middle  thirds  of  a  line 
between  the  anterior  superior  spine  and  the  navel  should  be  chosen 
for  the  insertion  of  the  needle.  Both  these  sites  will  escape  the 
deep  epigastric  artery  (Fig.  269). 

Position  of  the  Patient. — The  patient  either  sits  upright,  in  order 
to  allow  the  gravitation  of  the  fluid  to  the  lowest  level,  or  he  may  be 
propped  up  in  a  semireclining  position.  For  a  lateral  puncture  the 
patient  should  lie  upon  his  side. 

Preparation  of  the  Patient. — The  site  for  puncture  should  be 
shaved  and  properly  sterilized.  The  bladder  should  always  be  emptied 
inwiediately  before  tJie  operation. 


EXPLORATORY   PUNCTURE    OF   THE    LIVER 


269 


Anesthesia. — Infiltration  cocain  or  novocain  anesthesia  or  freez- 
ing with  ethyl  chlorid  will  suffice. 

Technic. — The  point  chosen  for  the  puncture  is  anesthetized,  and 
a  small  nick  is  made  in  the  skin.  The  needle  is  inserted  directly  back- 
ward until  the  resistance  of  the  abdominal  wall  is  no  longer  felt  and 
the  point  of  the  needle  moves  freely  within  the  abdominal  cavity. 
Sufficient  fluid  is  withdrawn  for  examination,  and,  after  removal  of 
the  needle,  the  site  of  entrance  is  closed  with  a  thin  layer  of  collodion 
and  cotton. 


Fig.  269. — Points  for  puncture  of  the  peritoneal  cavity. 


EXPLORATORY  PUNCTURE  OF  THE  LIVER 

Exploration  of  the  liver  by  means  of  an  aspirating  needle  may  be 
required  for  the  purpose  of  making  a  positive  diagnosis  in  cases  of 
suspected  amebic  or  pyogenic  abscess,  or  hydatid  cyst.  Exploratory 
puncture  should  not  be  performed,  however,  unless  the  preparations 
for  an  immediate  operation,  if  such  be  necessary,  are  completed 
beforehand,  for  no  matter  how  small  the  puncture  may  be,  leakage  of 
fluid  is  liable  to  occur  and  cause  serious  damage. 

Apparatus. — An  exploring  syringe,  needles,  a  scalpel,  test-tubes, 
etc.,  such  as  is  required  for  any  exploratory  puncture  (seepage  259), 
should  be  provided. 


270 


EXPLORATORY  PUNCTURES 


Location  of  the  Puncture. — This  will  depend  -upon  the  symptoms 
and  physical  signs  in  each  individual  case.  If  at  any  one  point  there 
be  localized  pain,  tenderness  on  palpation,  peritoneal  crepitation,  or 
distinct  bulging,  such  spot  should  be  chosen  for  the  puncture.  In 
the  absence  of  signs  pointing  to  localization,  the  fact  that  most  liver 
abscesses  are  situated  in  the  upper  posterior  portion  of  the  right  lobe 
should  be  borne  in  mind  and  the  puncture  made  accordingly,  the 
needle  being  inserted  in  the  midaxillary  line  on  the  right  side  through 
the  ninth,  tenth,  or  eleventh  interspace,  or  below  the  angle  of  the 
scapula  through  the  tenth  interspace  (Fig.  270).     Puncture  may  also 


Fig.  270. — Points  for  puncture  of  the  liver. 

be  made  anteriorly  directly  into  the  area  of  liver  dullness  below  the 
line  of  the  pleura. 

Asepsis. — The  operation  is  performed  under  all  aseptic  precau- 
tions (see  page  262). 

Anesthesia. — The  puncture  may  be  made  under  local  anesthesia, 
but,  if  it  is  likely  that  a  number  of  punctures  will  be  necessary  and  an 
operation  is  to  be  performed,  it  is  better  to  give  a  general  anesthetic 
at  the  start. 

Technic— After  making  a  small  nick  in  the  skin  with  a  scalpel  at 
the  site  chosen  for  the  puncture,  the  needle  is  slowly  introduced 
inward  and  slightly  upward  to  its  full  extent,  and  suction  is  attempted. 


EXPLORATORY    PUXCTURE    OP    THE    SPLEEN  271 

If  fluid  i5  not  obtained,  the  needle  is  slowly  withdrawn,  a  vacuum 
being  maintained  in  the  syringe  in  the  meantime,  so  as  to  withdraw 
pus  in  case  the  point  of  the  needle  has  previously  passed  through  a 
ca\-ity  into  healthy  tissue.  Near  the  surface  of  the  liver  the  direc- 
tion of  the  needle  is  altered,  and  it  is  inserted  again  in  a  different 
plane.  In  this  manner  a  large  area  of  the  HA'er  may  be  explored  in 
aU  directions  from  one  external  puncture,  provided  care  is  exercised 
not  to  injure  the  pleura  and  lung  above,  or  the  gall-bladder  and 
intestines  below.  The  needle  should  not  be  inserted  to  a  greater 
depth  than  3  3,  4  (9.5  cm.)  inches  from  the  surface  of  the  body  for 
fear  of  injuring  the  inferior  vena  cava.  To  avoid  lacerating  the 
liver,  the  exploring  needle  must  be  allowed  to  move  freely  with  the 
liver  as  it  rises  or  descends  during  respiration.  If  fluid  is  not  immedi- 
ately found,  a  number  of  punctures  should  be  made  before  the  opera- 
tion is  abandoned.  Failure  to  draw  pus  into  the  s}Tinge  does  not 
necessarily  signify  absence  of  an  abscess,  for  at  times  the  material 
forming  the  abscess  is  so  thick  that  it  wiU  not  pass  into  the  needle, 
and  only  a  drop  or  two  of  pus  will  be  discovered  on  close  examination, 
clinging  to  the  needle  point. 

Having  located  an  abscess,  the  needle  should  be  left  in  situ  as  a 
guide,  for  it  is  not  an  uncommon  experience,  when  pus  is  discovered 
by  aspiration  and  the  needle  removed,  to  fail  to  locate  the  abscess  at  a 
subsequent  operation. 

EXPLORATORY  PUNCTURE  OF  THE  SPLEEN 

As  a  diagnostic  measure,  puncture  of  the  spleen  may  be  performed 
\\-ithout  danger  if  the  organ  is  hard,  as  is  found  in  chronic  malaria, 
but  in  infectious  diseases  with  a  large,  soft,  and  friable  spleen  it  is 
an  unjustifiable  procedure.  Laceration  of  the  capsule  followed  by 
hemorrhage,  suppuration  in  the  spleen,  and  peritonitis  have  been 
known  to  result.  Likewise  puncture  of  the  spleen  in  suspected  cases 
of  t}'phoid  fever  is  no  longer  warranted,  since  we  have  other  methods 
of  diagnosis,  such  as  Widal's  test,  which  are  both  safe  and  adequate. 
When  fluctuation  has  been  demonstrated,  as  in  splenic  abscess  or 
hydatid  disease,  examination  of  the  fluid  obtained  by  aspiration  may 
give  conclusive  information;  but  here  again,  as  in  exploratory  punc- 
tures of  the  liver  or  lungs,  preparations  for  incision  and  drainage,  in 
case  such  should  be  necessary,  should  be  completed  before  the 
puncture  is  made. 

Apparatus. — Exploring  needles,  an  aspirating  syringe,  and  other 


272 


EXPLORATORY  PUNCTURES 


instruments  necessary  for  any  exploratory  puncture  (see  page  259) 
should  be  provided. 

Location  of  Puncture. — The  spleen  can  be  reached  by  insert- 
ing the  needle  through  the  tenth  intercostal  space  in  the  midaxillary 
line  on  the  left  side  (Fig.  271),  If  the  organ  is  markedly  enlarged, 
some  point  below  the  left  costal  margin,  determined  by  percussion  of 
the  spleen,  may  be  chosen. 

Position  of  the  Patient. — The  patient  may  assume  either  the 
sitting  posture  with  the  left  arm  elevated  and  the  hand  on  the  oppo- 


FlG.  271. — Point  for  puncturing  the  spleen. 


site  shoulder,  or  the  recumbent  position,  depending  upon  which 
gives  the  most  ready  access  to  the  region  of  operation. 

Asepsis. — The  same  as  for  any  exploratory  puncture  (see  page 
262). 

Anesthesia. — ^Local  infiltration  anesthesia  or  freezing  will  suffice. 

Technic. — A  fine  and  fairly  long  aspirating  needle  should  be 
employed.  The  patient  is  instructed  to  hold  his  breath,  to  lessen  the 
danger  of  lacerating  the  organ,  and  the  operator  makes  a  small  nick 
in  the  skin,  quickly  inserts  the  needle  at  the  chosen  site,  and  makes 
the  aspiration  with  as  httle  delay  as  possible.  The  needle  is  then 
withdrawn,  and  the  site  of  puncture  is  closed  with  a  thin  covering  of 
collodion  and  cotton. 


EXPLORATORY    PUNCTURE    OF    THE    KIDNEYS 


273 


EXPLORATORY  PUNCTURE  OF  THE  KIDNEYS 

Exploratory  aspiration  may  be  employed  to  detect  collections  of 
pus  or  other  fluids  in  the  region  of  the  kidney.  An  exploratory 
incision,  however,  and  subsequent  aspiration  after  exposure  of  the 
mass  is  a  far  more  satisfactory  method  of  diagnosis. 

Apparatus. — An  aspirating  syringe,  exploring  needles,  and  other 
apparatus  necessary  for  making  an  exploratory  puncture  (see  page 
259)  should  be  at  hand. 

Location  of  the  Puncture. — The  needle  should  be  introduced  at  a 
point  about  2  1/2  inches  (6  cm.)  from  the  median  line,  to  avoid  the 


Fig.  272. — Showing  the  relations  of  the  kidneys  from  behind. 

erector  spinas  muscles,  and  a  httle  below  the  last  rib  on  the  left  side, 
and,  on  the  right  side,  between  the  last  rib  and  the  crest  of  the  ilium. 

Position  of  Patient. — The  patient  may  sit  up,  with  the  back  bent 
forward,  or  he  may  lie  partly  upon  the  unaffected  side  and  partly  upon 
the  abdomen,  with  the  body  bent  forward  in  a  curve. 

Asepsis. — The  usual  aseptic  precautions  are  to  be  observed  (see 
page  262). 

Anesthesia. — ^Local  infiltration  anesthesia  or  freezing  will  sufhce. 

Technic. — A  long  fine  needle  should  be  employed.  After  nicking 
the  skin  with  a  scalpel  at  the  site  chosen  for  the  puncture,  the  needle 
18 


274  EXPLORATORY    PUNCTURES 

is  slowly  introduced  forward  and  slightly  inward  toward  the  median 
line,  frequent  tests  at  aspiration  being  made  as  the  needle  is  advanced. 
When  fluid  is  discovered,  a  sufficient  quantity  for  diagnosis  is  with- 
drawn, and  the  site  of  puncture  is  sealed  with  a  cotton  and  collodion 
dressing. 

EXPLORATORY  PUNCTURE  OF  JOINTS  • 

This  constitutes  a  most  valuable  aid  in  ascertaining  the  character 
of  a  joint  effusion.  Therapeutic  puncture  of  joints  for  the  purpose 
of  injecting  fluids  in  the  treatment  of  tuberculous  synovitis  and 
acute  infections  involving  joints  is  also  becoming  a  frequent  opera- 
tion. Puncture  of  a  joint  is  not  difficult  if  the  joint  is  distended 
with  fluid.  Care  should  be  exercised  not  to  insert  the  needle  at  a 
point  where  blood-vessels  or  important  nerves  would  be  encountered 
and  to  avoid  producing  any  injury  to  the  cartilage  of  the  joint,  lest 
serious  complications  result. 

Apparatus. — Exploring  needles,  a  glass  aspirating  syringe,  a 
scalpel,  a  cocain  syringe,  etc.,  should  be  provided  (see  page  259). 

Asepsis. — Puncture  of  a  joint,  as  all  exploratory  punctures 
should  be  made  under  all  aseptic  precautions.  The  instruments 
are  to  be  sterilized  by  boiling,  the  operator's  hands  are  as  carefully 
prepared  as  for  any  operation,  and  the  site  of  puncture  is  painted 
with  tincture  of  iodin. 

Anesthesia. — Local  infiltration  is  employed. 

Technic. — The  skin  over  the  site  of  puncture  is  infiltrated  with  a 
0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  novocain  solution  and 
the  deeper  tissues  down  to  the  joint  capsule  are  similarly  anesthe- 
tized. A  small  nick  is  then  made  in  the  skin  at  the  point  chosen  for 
insertion  of  the  needle,  and  the  needle  is  inserted  into  the  joint  in  the 
same  manner  as  for  any  exploration  puncture. 

The  sites  for  puncture  of  those  joints  to  which  the  method  is 
most  often  apphed  are  as  follows: 

The  Shoulder=joint. — Entrance  to  the  joint  is  best  eft'ected  by 
introducing  the  needle  from  the  side  through  the  groove  between  the 
acromion  process  and  the  head  of  the  humerus.  The  direction  of  the 
needle  should  be  somewhat  downward  and  backward  (Fig.  273),  if  it 
is  inserted  straight  in  from  the  side  it  is  apt  to  enter  the  subacromial 
bursa. 

The  Elbow=joint. — Puncture  of  the  joint  may  be  made  from 
behind  or  from  the  outer  side. 

To  enter  the  joint  from  behind,  the  forearm  is  flexed  to  an  angle 


EXPLORATORY    PUXCTURE    OF    JOINTS 


7o 


of  135  degrees,  and  the  needle  is  inserted  downward  and  forward 
behind  the  olecranon  (Fig.  274). 

To  pnnctiire  the  joint  from  the  outer  side,  the  arm  is  flexed  and 
the  radial  head  is  identified  by  the  finger  as  the  forearm  is  rotated. 
The  needle  is  then  inserted  into  the  joint  between  the  external  con- 
dyle of  the  humerus  and  the  head  of  the  radius. 

The  Wrist-joint. — The  joint  is  best  entered  from  the  dorsal  sur- 
face, inserting  the  needle  near  the  radius  between  the  tendons  of  the 


Fig.  273. — Point  for  puncturing 
the  shoulder- joint 


Fig.   274. — Point  for  puncturing  the 
elbow-joint. 


extensor  indicis  and  the  extensor  longus  pollicis  at  the  level  of  a  line 
joining  the  styloid  process  of  the  radius  and  that  of  the  ulna. 

The  Hip-joint. — The  hip  may  be  readily  entered  by  the  exploring 
needle  from  in  front,  at  what  is  known  as  Biingner's  point,  or  from 
the  side. 

Anterior  puncture  is  performed  as  follows:  A  spot  is  chosen 
midway  on  a  line  joining  the  point  at  which  the  femoral  artery 
emerges  from  under  Poupart's  ligament  and  the  tip  of  the  great  tro- 
chanter (Fig.  275),  and,  wdth  the  femoral  artery  identified  by  the 
forefinger  of  the  left  hand  to  avoid  injuring  it.  the  needle  is  pushed 
directly  back  into  the  joint. 

For  a  lateral  puncture  the  leg  should  be  slightly  adducted.  The 
needle  is  then  pushed  into  the  joint  toward  the  median  fine  of  the 
body  from  the  side  just  above  the  great  trochanter  (see  Fig.  275). 

The  Knee=joint. — The  needle  may  be  inserted  into  either  side  of 
the  joint — but  preferably  in  the  outer  side—  beneath  the  patella  at  a 


276 


EXPLORATORY   PUNCTURES 


point  where  fluctuation  or  distention  is  most  in  evidence.  When  the 
swelling  is  more  marked  above  the  patella,  the  needle  may  be  intro- 
duced from  above  downward  behind  the  bone  (Fig  276),  the  operator's 


Pig.  275. — Points  for  puncturing   the   hip-joint    (modified    from   Pels-Leusden). 

left  hand  grasping  the  joint  below  the  patella  and  forcing  the  intra- 
articular fluid  upward  into  the  suprapatellar  recess. 

The  Ankle=joint. — To  avoid  injuring  the  vessels  and  nerves 
which  lie  opposite  the  middle  of  the  joint,  the  needle  should  be  intro- 


FiG.  276. — Point  for  puncturing  the  knee-joint 


duced  from  in  front  midway  between  the  bundle  of  tendons  which 
pass  in  front  of  the  joint  and  the  corresponding  malleolus.  On  the 
inner  side  the  needle  is  inserted  1/2  inch  (i  cm.)  above  the  malleolar 


EXPLORATORY    PUNCTURE    OF    JOINTS 


277 


process  in  a  direction  obliquely  outward  and  backward;  on  the  outer 
side  the  needle  enters  3/4  of  an  inch  (2  cm.)  above  the  malleolar 
process  in  a  direction  obHquely  inward  and  backward. 


SPINAL  OR  LUMBAR  PUNCTURE 

Lumbar  puncture,  anx)peration  first  proposed  by  Quincke  for  the 
withdrawal  of  cerebrospinal  fluid  from  the  spinal  canal,  has  both 
diagnostic  and  therapeutic  value.  This  procedure  is  of  diagnostic 
importance  through  the  information  that  may  be  obtained  in  estimat- 
ing the  pressure  of  the  cerebrospinal  fluid  and  determining  its  char- 


FiG.  277. — Anatomy  of  the  lumbar  vertebra. 

acteristics  by  physical,  chemical,  microscopical,  and  bacteriological 
examination. 

Among  its  therapeutic  uses  is  its  employment  as  a  "decom- 
pressive agent,"  in  cases  of  meningitis,  hydrocephalus,  intracranial 
tumors,  cerebral  abscess,  uremia,  etc.,  etc.  On  account  of  the  con- 
tinuity of  the  spaces  in  the  brain  and  spinal  column,  temporary  rehef 
of  intracranial  and  intraspinal  pressure  may  be  obtained  in  the  above 
cases  by  the  withdrawal  of  small  amounts  of  fluid  from  the  spinal 
canal.  Lumbar  puncture  should  be  employed  with  great  caution, 
however,  in  cases  of  brain  tumor,  for  sudden  death  may  follow 
removal  of  a  large  amount  of  fluid,  the  increased  intracranial  tension 
causing  the  medulla  to  be  forced  against  the  foramen  magnum  when 
the  intraspinal  pressure  is  reheved.  In  cerebrospinal  meningitis, 
drainage  by  lumbar  puncture  is  often  followed  by  good  results^  as 


278 


EXPLORATORY   PUNCTURES 


not  only  is  the  pressure  upon  the  cord  and  cerebral  centers  lessened, 
but  pus  is  withdrawn,  and  the  toxicity  of  the  spinal  fluid  is  thereb}' 
diminished. 

It  is  in  the  administration  of  antitetanic  serum  and  antiserum 
in  cerebrospinal  meningitis,  and  the  production  of  spinal  anes- 
thesia, however,  that  lumbar  puncture  finds  its  chief  therapeutic 
applications. 


Fi(..   278. — -Stylet  needle  for  spinal  jjuncture. 

•Anatomy. — In  the  lumbar  portion  of  the  vertebral  column  the  spi- 
nous processes  do  not  project  downward  to  such  a  degree  as  in 
other  portions,  and  there  is  a  distinct  space  (about  7/8  inch  (22  mm.) 
in  the  transverse  and  3/5  inch  (15  mm.)  in  the  vertical  diameter) 
between  the  vertebral  arches  filled  with  ligaments  through  which  a 
needle  may  be  readily  passed  into  the  spinal  canal  (Fig.  277.)     The 


H 


IX  3  ^ 

Pig.  279,     Apparatus  tor  spinal  puncture,      i,  Scalpel;  2,  ethyl  chlorid  tube;  3, 
small  glass  graduate;  4,  hydrometer;  5    sterile  test-tube;  6   culture  tubes. 

spinal  cord  reaches  only  to  the  second  lumbar  vertebra,  so  if  the  punc- 
ture be  made  below  that  point,  and  the  introduction  of  the  needle  be 
carried  out  under  rigid  asepsis  the  operation  is  practically  harmless. 
The  Needle. — The  puncture  is  best  made  with  a  special  stylet 
needle  devised  for  the  purpose.  It  should  be  of  platinum  or  nickel,  at 
least  3  1/2  inches  (9  cm.)  long  and  about  1/25  of  an  inch  (i  mm.)  in 


SPINAL    OR    LUMBAR   PUNCTURE 


279 


diameter,  and  the  point  should  be  short  and  ground  almost  squarely 
across  (Fig.  278).  In  the  absence  of  such  a  needle,  the  ordinary 
aspirating  needle  of  about  the  same  size  may  be  substituted.  In 
addition,  a  scalpel,  a  sterilized  graduated  test-tube,  culture  tubes, 
and  an  ordinary  hydrometer  (Fig.  279)  will  be  required.  When  it 
is  desired  to  estimate  accurately  the  cerebrospinal  pressure,  a  small 
mercury  manometer  will  also  be  required. 

Location  of  the  Puncture. — ^The  space  between  the  third  and 
fourth  or  that  between  the  fourth  and  fifth  lumbar  vertebrae  is  usually 
chosen  (Fig.  280),  though,  if  the  puncture  is  performed  for  diagnostic 
purposes,  it  may  be  made  lower — between  the  fifth  lumbar  and  first 
sacral  vertebrae  in  order  to  withdraw  any  sediment  that  may  be 
present.     A  point  just  below  the  tip  of  the  spinous  process  of  the 


Fig.   280. — Points  for  spinal  puncture. 

vertebra  forming  the  upper  boundary  of  the  chosen  interspace  at  a 
distance  of  about  1/2  inch  (i  cm.)  to  one  side  of  the  median  line  is 
selected  for  the  insertion  of  the  needle.  In  children,  however,  the 
spinous  processes  being  short,  the  needle  may  be  inserted  in  the 
median  line. 

The  spinous  processes  may  be  readily  identified  by  counting  down 
from  the  seventh  cervical  vertebra,  unless  the  individual  be  very 
stout.  If,  however,  any  difficulty  is  experienced  in  locating  this 
vertebra,  the  landmarks  may  be  quickly  determined  by  passing  a 
transverse  line  between  the  highest  points  of  the  iliac  crests  with  the 
patient  standing  erect,  and  it  will  be  found  that  such  a  line  passes 
through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra 
(Fig.  281). 


28o 


EXPLORATORY   PUNCTURES 


Position  of  the  Patient. — The  operation  may  be  performed  with 
the  patient  sitting  in  a  chair,  with  the  body  bent  well  forward  in  the 
form  of  a  curve  (Fig.  282),  so  as  to  widen  the  intervertebral  spaces  as 


Fig.  281. — Showing  the  method  of  locating  the  fourth  spinous  process  by  passing  a 
line  through  the  highest  points  of  the  iliac  crests. 

much  as  is  possible.  If  this  is  impracticable,  the  patient  may  lie  on 
his  left  side  with  his  knees  drawn  up,  shoulders  forward,  and  body 
bent  forward  in  an  arch  (Fig.  283). 


Fig.   282. — -Sitting  posture  for  spinal  puncture. 

Asepsis. — The   site   for   the  puncture   should   be  painted   with 
iodin,  and  thorough   asepsis   must   be   observed   during   the   entire 


SPINAL   OR   LUMBAR   PUNCTURE 


26l 


operation.     The  needle  should  be  boiled  and  the  operator's  hands 
should  be  properly  sterilized. 

Anesthesia. — With  children  general  anesthesia  may  be  necessary. 
In  other  cases,  local  anesthesia  with  a  0.2  per  cent,  solution  of  cocain 


Fig.   283. — Lateral  position  for  spina]  puncture. 

or  a  I  per  cent,  novocain  solution,  or  by  freezing,  as  for  any  puncture, 
will  answer  all  purposes. 

Technic. — To  avoid  contaminating  the  needle  by  the  bacteria 
of  the  skin  as  well  as  to  make  the  insertion  of  the  rather  blunt  needle 
easier,  a  puncture  should  be  made  with  a  scalpel  through  the  skin  at 


Fig.  284. — Spinal  puncture.     First  step,  nick-      Fig.   285. — Spinal  puncture.     See- 
ing the  skin  at  the  point  of  puncture.  end  step,  inserting  the  needle. 

the  chosen  spot  (Fig.  284).  The  operator's  left  thumb  or  index  finger 
is  then  placed  between  the  two  spinous  processes  as  a  guide,  and  the 
point  of  the  needle  is  inserted  on  the  same  level  as  the  finger  about  1/2 
inch  (i  cm.)  from  the  median  line,  in  an  upward  and  inward  direction 


282  EXPLORATORY  PUNCTURES 

(Fig.  285).  until  it  enters  the  spinal  canal.  In  a  child  this  will  usu- 
ally occur  at  a  depth  of  from  3/4  to  i  1/2  inches  (about  2  to  4  cm. ) 
and  in  an  adult  from  2  1/2  to  3  inches  (about  6  to  7.5  cm.).  If  the 
needle  strikes  bone,  it  should  be  shghtly  withdrawn  and  then  rein- 
serted, its  direction  being  changed  somewhat. 

As  soon  as  the  canal  is  entered,  the  stylet  is  withdrawn,  and  the 
fluid,  as  it  oozes  from  the  needle  drop  by  drop,  is  collected  in  a  sterile 
test-tube  (Fig.  286).  The  first  few  drops  are  usually  blood  stained, 
and,  if  so,  they  should  be  discarded.  Not  more  than  i  1/4  drams 
(about  5  c.c.)  of  fluid  should  be  withdrawn  from  the  spinal  canal  of  a 


Fig.   286. — .Spinal  puncture.     Third  step,  collecting  the  cerebrospinal  fluid. 

child,  nor  more  than  1/2  ounce  (15  c.c.)  from  an  adult,  at  one  time 
for  diagnostic  purposes.  When,  however,  the  puncture  is  performed 
to  relieve  intracranial  pressure,  from  i  ounce  to  i  1/2  ounce  (30  to 
45  c.c.)  of  fluid  may  be  removed,  according  to  the  tension,  and  even 
more  if  no  ill  effects  are  observed.  Withdrawal  of  too  much  fluid 
may  cause  dizziness,  pallor,  sweating,  and  vomiting  and  later  a 
sharp  headache.  A  dry  puncture  is  sometimes  encountered  and  may 
be  due  to  the  needle  not  entering  the  canal,  to  its  being  plugged,  or 
from  the  fluid  being  too  thick  to  flow  through  its  lumen. 

At  the  completion  of  the  operation,  the  site  of  puncture  is  sealed 
with  collodion  and  cotton  and  the  patient  is  kept  recumbent  in  bed 
for  24  hours. 

Normal  Cerebrospinal  Fluid  and  its  Pathological  Variations. — 
Normally,  the  cerebrospinal  fluid  escapes  slowly,  while  in  certain 
diseased  conditions  with  increased  pressure,  as  meningitis,  tumor  of 
the  brain,  uremia,  paresis,  hydrocephalus,  etc.,  and  in  certain  infec- 


SPINAL    OR    LUMBAR   PU^XTURE  283 

tious  diseases,  it  may  spurt  out.  The  pressure  may  be  roughly 
estimated  by  the  strength  of  the  flow  from  the  needle,  a  strong  spurt 
of  fluid  indicating  an  increased  amount  of  pressure,  and  very  slow- 
coming  drops  the  reverse.  It  may  be  more  accurately  measured  by 
attaching  to  the  needle  a  small  mercury  manometer  by  a  smaU  rubber 
tube,  8  to  16  inches  (20  to  40  cm.)  long,  filled  with  a  i  per  cent,  solu- 
tion of  carbolic  acid.  This,  of  course,  is  to  be  done  before  any  of  the 
fluid  is  permitted  to  escape.  According  to  Sahli.  the  normal  dural 
pressure  in  the  horizontal  position  is  60  to  100  mm.  of  water  (5  to  7.3 
mm.  of  mercury),  and  200  to  800  mm.  of  water  (15  to  60  mm.  of 
mercury)  in  certain  pathological  conditions. 

Normal  cerebrospinal  fluid  is  colorless  and  water-like  in  clearness, 
of  alkaline  reaction,  has  a  specific  gravity  of  1006  to  1008  and  exists 
in  the  spinal  canal  in  but  small  amounts,  varying  between  1/2  and  2 
ounces  (15  and  60  c.c.)  in  adults  and  in  infants  between  2  1/2  and  5 
drams  (10  and  20  c.c).  In  certain  infectious  diseases,  intracranial 
tumor,  meningitis,  hydrocephalus,  general  paresis,  etc.,  the  amount 
of  cerebrospinal  fluid  may  be  greatly  increased.  It  contains  but 
little  albumin  (0.02  to  0.05  per  cent.),  some  chlorids  (0.7  per  cent.), 
a  copper-reducing  body  claimed  to  be  glucose,  and  traces  of  urea 
(0.035  to  0.04  per  cent.).  In  nephritis  and  uremia,  the  urea  is 
largely  increased  and  the  amount  of  chlorids  may  rise  slightly;  in 
hydrocephalus  there  may  be  a  shght  increase  in  the  urea.  In  apo- 
plexy, meningitis,  paresis,  hydrocephalus,  and  brain  tumor,  the  quan- 
tity of  albumin  may  be  markedly  increased.  A  bloody  or  blood- 
stained fluid  will  be  found  in  intrameningeal  cranial  hemorrhages  and 
in  injuries  of  the  skull  extending  through  the  dura,  but  in  injuries 
outside  the  dura  the  fluid  will  be  clear;  bloody  fluid  may  also  occur  in 
meningitis.  In  jaundice  it  may  be  greenish-yellow  in  color.  A 
cloudy,  purulent  fluid  indicates  inflammation  of  the  meninges,  as  does 
a  rise  in  the  specific  gravity,  and  the  appearance  of  white  blood 
cells  on  examination.  In  tubercular  meningitis,  however,  the  fluid  is 
clear  and  limpid,  and  there  is  present  a  high  lymphocytosis.  It  is 
only  possible  to  determine  the  specific  form  of  infection  by  bacterio- 
logical examination.  Identification  of  the  diplococcus  intracellularis, 
pneumococcus,  streptococcus,  or  tubercle  bacilli  \^'ill  definitely  settle 
the  nature  of  the  infection. 

Lumbar  Puncture  as  a  Means  of  Administering  Antitoxic 
Sera. — When  lumbar  puncture  is  employed  for  the  purpose  of  ad- 
ministering sera  in  tetanus  and  cerebrospinal  meningitis,  a  fairly  large 
syringe,  one  with  a  capacity  of  at  least  i  ounce  (30  c.c),  is  required  in 


284  EXPLORATORY  PUNCTURES 

addition  to  the  other  instruments  necessary  for  spinal  puncture.  The 
puncture  is  made  in  the  manner  described  above,  and  a  quantity  of 
cerebrospinal  fluid  equal  to  the  amount  of  serum  to  be  injected  is 
allowed  to  escape  from  the  canal;  the  serum  is  then  warmed  and  is 
slowly  injected  through  the  same  needle  employed  for  the  puncture. 

In  cases  of  tetanus,  Rogers  {Journal  oj  the  American  Medical 
Association,  July  i,  1905).  injects  2  1/2  to  5  drams  (10  to  20  c.c.)  of 
an ti tetanic  serum  into  the  nerves  of  the  cauda  equina,  as  well  as 
subcutaneously  in  the  neighborhood  of  the  wound,  intravenously,  and 
into  the  nerves  of  the  brachial  plexus  if  the  site  of  infection  is  upon  the 
upper  extremity,  and  into  the  sciatic  and  anterior  crural  nerves  if  the 
wound  is  in  the  lower  extremity.  In  making  the  spinal  injection  the 
needle  is  inserted  in  the  space  between  the  second  and  third  lumbar 
vertebrae,  so  as  to  strike  the  cauda  equina,  and  is  manipulated  back 
and  forth  with  the  object  of  wounding  some  of  the  nerves,  which  is 
manifested  by  twitching  of  the  legs;  2  1/2  to  5  drams  (10  to  20  c.c.) 
of  serum  are  then  injected  into  and  around  these  injured  nerves. 

For  cases  of  cerebrospinal  meningitis,  i  to  i  1/2  ounces  (30  to 
45  c.c.)  of  serum  are  injected  into  the  third  or  fourth  lumbar  space 
after  a  like  amount  of  cerebrospinal  fluid  has  been  evacuated.  Sub- 
sequent injections  are  given  at  intervals  of  twelve  to  twenty-four 
hours,  according  to  the  severity  of  the  case,  for  three  or  four  days.  If 
after  a  lapse  of  several  days  the  symptoms  return,  another  series  of 
injections  is  given.  In  place  of  a  syringe,  a  glass  funnel  holding 
about  5  drams  (20  c.c.)  attached  to  the  needle  by  rubber  tubing  may 
be  employed  for  administering  the  serum,  as  advised  by  Koplik. 


CHAPTER  XII 
ASPIRATIONS 

ASPIRATION  OF  THE  PLEURAL  CAVITY 

Paracentesis  thoracis,  also  spoken  of  as  thoracentesis  and  pleuro- 
centesis,  consists  in  the  evacuation  of  fluid  from  the  pleural  cavities 
by  means  of  a  hollow  needle  or  trocar  to  which  an  aspirator  is 
attached. 

Indications. — When  the  presence  of  fluid  has  been  made  out  by 
the  physical  signs  and  the  diagnosis  verified  by  an  exploratory  punc- 
ture, thoracentesis  is  indicated  in  sero-fibrinous  effusions  under  the 
following  conditions: 

1.  When  the  fluid  is  sufficient  to  produce  dyspnea,  cyanosis,  and 
cardiac  weakness. 

2.  In  very  large  effusions  whether  or  not  pressure  symptoms 
are  present,  especially  if  bilateral. 

3.  When  the  heart  is  displaced  by  the  presence  of  fluid. 

4.  When  the  fluid  is  not  absorbed  within  a  week  or  ten  days  in 
spite  of  medical  treatment. 

The  advantages  of  early  aspiration  are  that  adhesions  may  be 
prevented  and  the  course  of  the  disease  considerably  shortened. 
Long  continued  pressure  upon  the  lung  by  an  effusion  may  prevent 
its  subsequent  full  expansion,  and  reappearance  of  the  fluid  is  more 
apt  to  occur  when  the  operation  has  been  delayed. 

Apparatus,  Etc.— Evacuation  of  the  fluid  is  accomplished  by 
means  of  suction;  for  this  purpose  a  hollow  needle  or  a  trocar  con- 
nected with  either  an  aspirator  or  a  syphonage  apparatus  may  be 
employed.  In  addition,  a  scalpel,  and  collodion  and  cotton,  or  a 
pad  of  sterile  gauze  and  adhesive  plaster  for  the  dressing,  should 
be  supplied. 

The  Aspirating  Needle. — Whether  an  ordinary  aspirating  needle 
or  trocar  and  cannula  be  employed  does  not  make  any  material 
difference,  though  the  latter  has  some  advantages.  Where  the  tro- 
car form  of  needle  is  employed  the  point  of  the  cannula  may  be 
moved  about  without  danger  after  the  stylet  is  removed,  and,  should 
the  lumen  of  the  cannula  become  plugged,  the  obstacle  may  be  re- 

285 


286 


ASPIRATIONS 


moved  without  the  necessity  of  withdrawing  the  cannula  b\'  simple- 
reinserting  the  stylet.  With  an  aspirating  needle,  on  the  other  hand, 
the  unprotected  point  of  the  needle  may  injure  the  lung  or  diaphragm, 
and,  furthermore,  should  the  lumen  of  the  needle  become  blocked, 
it  may  be  necessary  to  withdraw  it  entirely  in  order  to  clear  out  the 
obstruction.  If  an  aspirating  needle  is  used,  one  should  be  chosen  at 
least  3  inches  (7.5  cm.)  long  and  from  1/25  inch  (i  mm.)  to  1/12 
inch  (2  mm.)  in  diameter  depending  upon  the  consistency  of  the 
material  to  be  evacuated. 

In  a  properly  made  trocar  the  stylet  should  fit  the  point  of  the 
cannula  accurately,  and  the  cannula  and  stylet  should  gradually 
taper  to  a  point,  as  if  in  one  piece.  The  cannula  is  provided  with  a 
stopcock  near  the  proximal  end  to  prevent  leakage  of  air  when  the 
stylet  is  withdrawn,  while  a  lateral  opening,  for  connection  with  the 
aspirator,  is  placed  at  a  point  distal  to  this  stopcock,  so  that  the  sty- 
let may  be  moved  back  and  forth  without  disturbing  the  connections 
(Fig.  287). 


Fig.   287. — Aspirating  trocar. 

Aspirators. — The  Potain,  the  Dieulafoy,  or  the  heat  vacuum 
apparatus  is  most  commonly  employed,  though  the  aspiration  may 
be  satisfactorily  made  in  a  large  proportion  of  cases  by  simple 
sjphonage.  The  Dieulafoy  instrument  is  most  convenient  for 
evacuating  small  collections  of  fluid  and  when  it  is  desirable  to  be  exact 
in  the  quantity  removed,  while  for  large  effusions  the  Potain  or  the 
heat  vacuum  apparatus  is  best. 

The  Potain  instrument  (Fig.  288)  consists  of  an  exhausting  pump. 
a  large  glass  bottle,  a  rubber  stopper  through  which  passes  the  long 
arm  of  a  Y-shaped  metal  tube  with  a  stopcock  in  each  limb,  and  two 
pieces  of  heavy  rubber  tubing,  one  connecting  the  needle  or  trocar 
with  one  arm  of  the  Y.  and  the  other  joining  the  second  arm  and  the 
exhausting  pump.  The  instrument  is  assembled  by  inserting  the 
stopper  firmly  into  the  glass  receptacle  and  attaching  one  end  of  a 
piece  of  tubing  to  the  stopcock  a  and  the  other  to  the  needle  or 


ASPIRATION    OF    THE    PLEURAL    CAVITY 


287 


trocar.  By  means  of  the  second  tubing  the  exhausting  syringe  is 
connected  with  stopcock  h.  The  instrument  should  be  carefully 
tested  before  using  to  see  that  all  the  connections  are  air-tight.  To 
produce  a  vacuum,  stopcock  a  is  closed  and  stopcock  h  is  opened, 


Fig.  288. — Potain  aspirator. 

when,  by  pumping  from  thirty  to  fifty  strokes,  the  air  will  be  suffi- 
ciently exhausted.  Stopcock  h  is  then  closed,  and  the  needle  is 
inserted  into  the  chest.  As  soon  as  its  point  enters  the  tissues,  the 
vacuum  is  extended  to  the  point  by  opening  stopcock  a,  so  that  the 
moment  fluid  is  reached  it  will  be  drawn  by  suction  into  the  bottle= 


Fig.  289. — The  Dieulafoy  aspirator. 

If  the  trocar  is  employed,  the  stylet  is  not  withdrawn  until  the  tro- 
car enters  the  chest;  as  this  is  done  the  stopcock  on  the  cannula  is 
closed,  so  as  to  exclude  air. 

The  Dieulafoy  apparatus  (Fig.  289)  consists  of  a  glass  syringe. 


255  ASPIRATIONS 

with  a  capacity  of  3  to  4  ounces  (90  to  120  c.c),  provided  with  two 
outlets,  each  furnished  with  a  stopcock,  and  to  which  are  fitted 
heavy  rubber  tubes.  To  the  extremity  of  one  tube  a  trocar  or 
aspirating  needle  is  attached,  and  at  a  distance  of  about  4  inches 
(10  cm.)  from  the  needle  end  a  piece  of  glass  tubing  is  inserted  as  an 
index.  The  other  piece  of  tubing  leads  from  stopcock  &  to  a  basin 
to  carry  ofif  the  fluid  discharged  from  the  cylinder.  To  use  the  in- 
strument both  stopcocks  are  closed,  and  the  piston  is  fully  withdrawn 
and  fixed  in  place  by  a  spring.     This  produces  the  vacuum.     The 


Fig.  290. — Connell's  heat  vacuum  aspirator. 

aspirating  needle  is  then  introduced  in  the  chosen  site,  and,  as  soon 
as  the  needle  point  is  buried  in  the  tissues,  the  stopcock  a  is  opened, 
allowing  the  vacuum  to  extend  to  the  needle.  The  needle  is  then 
pushed  on  in  until  it  enters  the  chest,  the  presence  of  fluid  being  first 
demonstrated  as  it  passes  through  the  glass  index.  When  the  aspi- 
rator is  filled,  stopcock  a  is  closed  and  stopcock  b  opened,  and  the 
fluid  is  discharged  from  b  by  driving  the  piston  back  in  place.  This 
process  of  aspiration  may  be  repeated  as  often  as  necessary  without 
removing  the  needle  or  disconnecting  the  aspirator. 

A  very  excellent  form  of  aspirator  and  one  that  is  frequently 
employed  is  the  vacuum  bottle  described  by  Connell  {Medical 
Record,  July  4,   1903).     It  consists  of  a  strong  glass  bottle  with  a 


ASPIRATION    OF    THE    PLEURAL    CAVITY 


289 


capacity  of  about  5  pints  (2.5  liters),  having  a  mouth  i  inch  (2.5 
cm.)  wide,  fitted  with  a  rubber  stopper  through  which  passes  a  glass 
tube  with  a  heavy  piece  of  rubber  tubing  attached,  ending  in  an 
aspirating  needle.  Three  drams  (12  c.c.)  of  95  per  cent,  alcohol  are 
poured  into  the  bottle  which  is  so  manipulated  that  its  inner  surface 
is  entirely  coated,  when  the  excess  of  alcohol  is  poured  off.  The 
alcohol  is  then  ignited,  and,  as  the  flame  reaches  the  bottom  of  the 
bottle,  the  cork  is  quickly  inserted,  the  rubber  tubing  having  been 
previously  clamped  (Fig.  290).  A  vacuum  is  thus  produced  which 
is  amply  sufficient  to  aspirate  a  chest. 

Removal  of  an  effusion  by  syphonage  may  be  readily  accom- 
pHshed  by  means  of  a  very  simple  apparatus.  A  piece  of  heavy 
tubing  about  3  feet  (90  cm.)  long,  a  clamp  to  close  one  end  of  the 


Fig.  291. — Syphonage  aspirator. 


tubing,  a  funnel,  sterile  water  or  sahne  solution  to  fill  the  tubing,  and 
a  receptacle  to  collect  the  fluid  are  the  necessary  requisites.  One 
end  of  the  tubing  is  fastened  to  a  large  caliber  needle  or  the  side  out- 
let of  the  trocar  and  the  other  to  the  glass  funnel  (Fig.  291). 

Site  of  Aspiration. — The  needle  should  be  inserted  at  a  point  where 
the  physical  signs  or  an  exploratory  puncture  demonstrate  the 
presence  of  fluid  and  at  the  lowest  level  of  the  fluid,  that  its  with- 
drawal may  be  facihtated  as  far  as  possible  by  the  action  of  gravity. 
The  sixth  intercostal  space  in  the  anterior  axiflary  fine,  the  sixth  or 
seventh  space  in  the  midaxillary  fine,  and  the  eighth  space  below 
the  angle  of  the  scapula  are  the  points  of  election  (Fig.  292). 

Quantity  Withdrawn. — It  is  not  essential  to  empty  the  chest  en- 
tirely at  one  sitting.  The  amount  of  fluid  evacuated  should  be  deter- 
19 


290 


ASPIRATIONS 


mined  more  by  the  manner  in  which  the  patient  bears  the  operation, 
the  condition  of  the  pulse,  and  signs  of  impending  collapse  rather  than 
by  the  quantity  of  fluid  present.  In  very  large  effusions  as  much  as 
3  pints  (1500  c.c.)  may  be  removed,  but  it  is  better  to  withdraw 
too  little  than  too  much,  for  what  remains  may  be  evacuated  at  a 
subsequent  period;  and  it  not  infrequently  happens  that  spontaneous 
absorption  of  the  eft'usion  follows  the  removal  of  even  small 
quantities. 

Position  of  Patient. — The  aspiration  is  preferably  performed  with 
the  patient  on  a  bed  so  as  to  avoid  the  extra  exertion  of  moving  after 


Fig.  292. — Sites  for  aspiration  of  the  pleura.     (The  large  dots  represent  the  points 

of  election.) 

the  operation.  When  possible,  an  upright  sitting  position  should 
be  assumed,  with  the  arm  of  the  affected  side  raised,  and  the  hand 
placed  on  some  support  or  on  the  opposite  shoulder  to  increase  the 
breadth  between  the  intercostal  spaces  (Fig.  293).  If  this  is  im- 
practicable, the  patient  may  lie  near  the  edge  of  the  bed,  upon  the 
back  for  a  lateral  puncture,  or  rolled  slightly  to  the  opposite  side  with 
the  arm  extended  over  the  head  for  a  posterior  puncture  (see  Fig.  262). 
Asepsis. — The  skin  at  the  site  of  operation  should  be  painted  with 
tincture  of  iodin;  the  operator's  hands  should  also  be  properly 
cleansed,  and  the  needle  or  trocar  sterilized  by  boiHng. 


ASPIRATION    OF    THE    PLEURAL    CAVITY 


291 


Anesthesia. — Local  anesthesia  by  freezing  with  ethyl  chlorid  or 
by  infiltration  with  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain  at  the  point  of  puncture  will  be 
sufficient. 


Fig.   293. — Position  of  patient  for  aspiration  of  the  pleura. 

Technic. — A  vacuum  is  first  produced  in  the  aspirator  and  the 
needle  or  trocar  attached.  A  point  is  then  selected  in  the  chosen 
interspace  at  a  little  distance  from  the  upper  margin  of  the  lower  rib 
bounding  the  space,  so  as  to  avoid  the  upper  intercostal  artery,  and 
the  skin  is  nicked  with  a  scalpel.     The  thumb  and  forefinger  of  the 


Fig.  294. — Method  of  holding  the  trocar. 

left  hand  are  used  to  steady  the  tissues  overlying  the  intercostal 
space,  while  the  needle  or  trocar  is  introduced  with  the  right  hand,  the 
forefinger  being  placed  on  the  needle  to  guard  against  its  being  in- 
serted too  deeply  (Fig.  294).  As  soon  as  the  point  of  the  needle 
enters  the  tissues,  the  vacuum  already  present  in  the  aspirator  is 


292 


ASPIRATIONS 


extended  to  the  needle  point  by  opening  the  proper  stopcock,  and  the 
needle  is  steadily  pushed  in  until  it  enters  the  pleural  sac,  which  will 
usually  be  at  a  depth  of  less  than  2  inches  (5  cm.).  The  fluid  should 
be  withdrawn  rather  slowly  in.  order  that  the  structures  may  have 
time  to  adjust  themselves  to  the  changed  conditions  in  the  chest; 
at  least  twenty  minutes  to  half  an  hour  should  be  consumed  in  re- 
moving 2  pints  fiooo  c.c). 

Should  the  patient  feel  faint  or  sufifer  from  vertigo  or  dyspnea 
the  operation  should  be  temporarily  interrupted  and  the  patient's 


Fig.   295. — Aspiration  of  the  pleura  with  the  Potain  apparatus. 


head  lowered.  Complaints  of  severe  pain,  persistent  cough,  or 
expectoration  of  blood  also  demand  that  the  aspiration  be 
discontinued. 

At  the  completion  of  the  operation  the  tissues  are  pinched  up 
around  the  shaft  of  the  needle  which  is  quickly  withdrawn.  The 
site  of  puncture  is  then  dressed  with  collodion  and  cotton,  or  with  a 
sterile  pad  of  gauze  held  in  place  by  adhesive  strips. 

In  employing  the  sj-phonage  apparatus  the  tubing  is  first  filled 
with  sterile  solution,  and  the  clamp  is  placed  near  the  end  of  the  tube 
to  prevent  the  solution  escaping.  The  needle  is  then  introduced 
into  the  chest,  while  the  free  end  of  the  tube  is  placed  under  water 
in  the  receptacle  provided  for  the  collection  of  the  fluid.     On  remov- 


ASPIRATION    OF    THE    PERICARDIUM  293 

ing  the  clamp  from  the  tube  the  column  of  water  is  released  and  the 
fluid  withdrawn  by  a  process  of  syphonage. 

Complications  and  Dangers. — Sepsis  is  not  to  be  feared  if  the 
ordinary  aseptic  precautions  are  observed. 

Pneumothorax  may  follow^  injury  to  the  lung  by  the  aspirating 
needle  or  trocar,  or  be  due  to  the  rupture  of  adhesions  or  a  cavity 
when  expansion  occurs,  or  to  the  entrance  of  air  along  the  trocar. 

Albuminous  expectoration  has  been  observed  as  a  sequel  to  the 
sudden  withdrawal  of  large  quantities  of  fluid.  The  expectoration 
consists  of  a  yellow^ish.  frothy  fluid,  and  it  is  accompanied  by  dysp- 
nea, cyanosis,  and  a  weak  pulse.  This  condition  usually  begins 
during  the  withdrawal  of  the  fluid,  or  comes  on  shortly  afterward. 
It  is  explained  on  the  supposition  that  the  rapid  withdrawal  of  fluid 
suddenly  removes  the  pressure  from  the  lung,  which  as  a  result 
becomes  congested,  and  transudation  into  the  air  cells  follows. 

Expectoration  of  blood  may  result  from  the  rupture  of  small  pul- 
monary vessels,  from  congestion  of  the  lung,  or  from  injury  to  the 
lung  tissue  by  the  aspirating  needle. 

Sudden  death  is  unusual,  though  it  may  occur,  and  at  times  with- 
out apparent  cause.  EmboHsm,  cerebral  anemia,  from  the  sudden 
rush  of  blood  to  the  expanding  lung,  hemorrhage  into  the  pleural 
cavities  from  injury  to  the  lung,  and  irritation  of  the  terminations  of 
the  pneumogastric  nerve  have  been  suggested  as  explanations. 

The  occurrence  of  these  complications  may  be  reduced  to  a 
minimum  by  the  employment  of  rigid  asepsis,  the  observance  of 
great  care  in  the  use  of  the  needle  or  trocar,  and  the  removal  of  only 
moderate  amounts  of  fluid  without  haste. 

ASPIRATION  OF  THE  PERICARDIUM 

Paracentesis  pericardii,  or  pericardicentesis,  consists  in  the  evacu- 
ation of  the  contents  of  the  pericardial  sac  through  aspiration  by 
means  of  a  needle  or  a  fine  trocar  attached  to  a  vacuum  apparatus. 

Indications. — Paracentesis  of  the  pericardium  should  be  per- 
formed: 

1.  If  the  eft'usion  is  sufficiently  large  to  endanger  Hfe  through 
profound  disturbance  in  the  cardiac  action  indicated  by  severe 
dyspnea,  small,  rapid,  and  irregular  pulse,  and  cyanosis,  the  indicatio 
vitalis,  as  death  may  result  from  syncope  if  the  condition  be  not 
relieved  without  delay. 

2.  When  a  large  effusion  does  not  show  any  tendency  to  absorp- 
tion after  a  prolonged  and  fair  trial  of  medical  means. 


294 


ASPIRATIONS 


In  the  presence  of  a  purulent  exudate,  though  temporary  relief 
may  be  obtained  by  aspiration,  the  condition  is  one  that  should  be 
treated  by  incision  and  free  drainage,  just  as  in  empyema. 

Apparatus,  Etc, — In  tapping  the  pericardium  a  Potain  or  Dieu- 
lafoy  aspirator  to  which  is  attached  a  fine  needle  or  trocar  and  can- 
nula may  be  employed  in  the  same  way  as  used  in  the  pleural  cavity; 
a  scalpel,  collodion  and  cotton,  or  gauze  and  adhesive  plaster  for 
the  purpose  of  dressings,  should  also  be  at  hand. 

Site  of  Aspiration. — The  point  for  making  the  aspiration  should 
be  determined  upon  after  having  first  detected  the  presence  of  fluid 


V     \  ~ i- 

5>\  ^ — -y^^y^r^ 

I  '\  V    y    --/ 
\  W  ~'     /' 


Fig.  296. — Points  for  aspiration  of  the  pericardium.  The  dotted  line  indicates 
a  distended  pericardial  sac.  The  course  of  the  internal  mammary  vessels  is  also 
shown. 

by  an  exploratory  puncture  (page  265).     For  the  introduction  of  the 
needle  there  are  four  sites  recommended: 

1.  In  the  fourth  or  fifth  intercostal  space  close  to  the  left  sternal 
margin,  or  else  i  inch  (2.5  cm.)  to  the  left  of  it,  thus  passing  either 
internal  or  external  to  the  internal  mammary  artery. 

2.  In  the  fifth  interspace  close  to  the  right  of  the  sternum. 

3.  Close  to  the  costal  margin  in  the  angle  between  the  ensiform 
cartilage  and  seventh  costal  cartilage  on  the  left,  inserting  the  needle 
upward  and  backward. 


ASPIRATION    OF    THE    PERICARDIUM  295 

4.  In  the  fifth  or  sixth  left  interspace  outside  the  nipple  line  be- 
tween the  apex  beat  and  outer  border  of  dullness  (Fig.  296), 

Quantity  Withdrawn. — In  small  effusions  the  fluid  may  be  re- 
moved at  one  sitting;  but  in  large  effusions,  in  order  to  avoid  suddenly 
removing  the  extracardial  pressure,  it  is  preferable  to  withdraw  not 
more  than  3  to  4  ounces  (90  to  120  c.c.)  at  the  first  sitting.  Thij 
may  be  followed  by  absorption  of  the  rest  of  the  fluid,  as  is  often  thf. 
case  in  pleurisy.  If  there  is  no  improvement  at  the  end  of  a  day  01 
two,  however,  it  will  be  necessary  to  perform  a  second  tapping. 

Position  of  Patient. — The  operation  may  be  performed  either  with 
the  patient  recumbent  or  sitting  upright. 

Asepsis. — The  greatest  regard  to  aseptic  precautions  should  be 
observed.  The  area  of  operation  should  be  shaved,  if  necessary,  and 
the  skin  painted  with  tincture  of  iodin.  The  operator's  hands  are 
thoroughly  cleansed,  and  the  apparatus  to  be  used  in  the  operation  is 
boiled. 

Anesthesia. — ^Local  anesthesia  by  freezing  with  ethyl  chlorid 
or  other  freezing  agents,  or  by  injecting  a  few  drops  of  a  0.2  per  cent, 
solution  of  cocain  or  a  i  per  cent,  solution  of  novocain  into  the  skin 
will  be  found  useful. 

Technic. — A  nick  is  made  through  the  skin  with  a  scalpel  at  a 
point  not  far  from  the  upper  margin  of  the  rib  forming  the  lower 
boundary  of  the  space  previously  determined  upon  for  aspiration. 
The  tissues  are  steadied  between  the  thumb  and  forefinger  of  the 
left  hand,  and  the  needle  is  held  in  the  right  hand,  the  index  finger 
being  placed  on  its  shaft  as  a  guide  to  the  proper  depth  of  insertion, 
as  shown  in  Fig.  294,  The  direction  of  the  needle  as  it  is  introduced 
should  be  at  first  backward,  until  it  enters  the  thorax,  and  then 
slightly  inward  into  the  pericardium;  but  if  the  approach  is  made 
in  the  left  seventh  costoxyphoid  angle,  the  needle  is  introduced 
directly  upward  and  backward.  The  introduction  of  the  needle 
must  be  performed  slowly,  steadily,  and  with  great  care.  The 
vacuum  previously  produ^ced  in  the  aspirator  is  extended  to  the 
needle,  by  opening  the  proper  valve,  as  soon  as  the  needle  point  enters 
the  tissues,  so  that  fluid  will  be  withdrawn  at  the  earliest  possible 
moment  and  thus  injury  to  the  heart,  through  inserting  the  needle 
too  deeply,  will  be  avoided.  Usually  at  a  depth  of  i  inch  (2.5  cm.) 
the  pericardium  will  be  entered.  Care  must  be  taken  not  to  produce 
too  great  a  vacuum  in  the  aspirator  lest  the  fluid  be  withdrawn  too 
rapidly — it  should  simply  trickle  into  the  aspirator. 

As  soon  as  the  desired  quantity  is  removed,  the  aspirating  needle 


296 


ASPIRATIONS 


is  quickly  withdrawn,  and  the  seat  of  puncture  is  occluded  with 
cotton  and  collodion,  or  else  by  a  pad  of  sterile  gauze  held  in  place 
by  adhesive  plaster. 

Complications  and  Dangers. — It  should  be  remembered  that 
aspiration  of  the  pericardium  is  no  simple  procedure,  but  is  an  opera- 
tion attended  by  danger.  Infection  of  the  pericardium,  injury  to 
the  internal  mammary  vessels,  puncture  of  the  pleura,  and  lacera- 
tion of  the  coronary  artery  and  the  heart  itself  by  the  aspirating  needle 
have  all  been  observed.  Strict  attention  to  asepsis,  extreme  care 
in  introducing  the  aspirating  needle  or  trocar,  and  observance  of  the 
various  points  in  technic  that  have  been  emphasized  will  do  much  in 
preventing  such  accidents. 


ASPIRATION  FOR  ASCITES 

Paracentesis  of  the  abdomen  consists  in  puncturing  the  perit- 
oneal cavity  by  means  of  a  trocar  and  cannula  and  withdrawing  the 
fluid  therein  contained.  It  is  an  operation  attended  by  practically 
no  risks  and  can  safely  be  repeated  many  times  in  the  same  individual 
when  necessary. 

Indications. — The  abdomen  may  be  aspirated  in  cases  of  ascites 
when  the  physical  signs  show  the  presence  of  fluid,  and  distention 


Fig.   297. — Trocar  and  cannula  for  aspirating  the  peritoneal  cavity,      i,   Trocar 
and  cannula  assembled;  2,  showing  trocar  removed  from  the  cannula. 

becomes  distressing  from  pressure  upward  upon  the  diaphragm.  It 
should  also  be  performed  when  the  fluid  reaccumulates  after  a 
previous  tapping  and  gives  rise  to  pressure  symptoms. 

Instruments,  Etc. — A  straight  or  slightly  curved  cannula  and 
trocar  of  fair  size— about  1/16  to  1/8  inch  (1.5  to  3  mm.)  in  diameter 
— should  be  used.  The  trocar  is  spear-pointed  and  should  lit  the 
cannula  perfectly  so  as  to  prevent  the  point  of  the  latter  catching 
in  the  tissues  during  its  introduction  (Fig.  297) .     An  excellent  form  of 


ASPIRATION   FOR   ASCITES 


297 


cannula,  and  one  frequently  used,  contains  a  lateral  opening  about 
1/8  inch  (3  mm.)  from  its  end,  for  the  purpose  of  avoiding  stoppage 
of  the  escaping  fluid,  should  the  intestines  or  omentum  obstruct 
the  end  opening  of  the  instrument. 

If  desired,  the  aspirating  apparatus  of  Potain  or  Dieulafoy  (page 
286)  may  be  used  in  place  of  the  simple  trocar. 

In  addition  a  scalpel  to  make  a  small  preliminary  incision,  a 
sterile  abdominal  binder,  a  many-tailed  bandage  or  large  towel,  and 
collodion  and  cotton  or  sterile  gauze  and  adhesive  plaster  for  the 
dressing  should  be  provided. 


Fig.   298. — Sites  for  aspiration  of  the  peritoneal  cavity. 


Site  of  Puncture. — The  selection  of  a  location  free  from  vessels 
and  where  the  abdominal  wall  is  thin  is  desirable.  Usually  a 
point  in  the  linea  alba  midway  between  the  umbilicus  and  pubes  is 
selected,  but  the  puncture  may  be  at  a  point  in  the  linea  semilu- 
naris just  outside  the  rectus  muscle  at  the  junction  of  the  outer  and 
middle  thirds  of  a  line  between  the  umbilicus  and  the  anterior  supe- 
rior iliac  spine  (Fig.  298).  A  puncture  at  either  of  these  sites  will 
avoid  the  deep  epigastric  vessels.  Should  repeated  punctures  be 
made,  it  will  be  of  advantage  to  change  the  site  a  little  each  time  so  as 
to  avoid  entering  adhesions  which  may  have  been  produced  by  a 
previous  puncture. 


298 


ASPIRATIONS 


Quantity  Withdrawn. — Whether  all  the  fluid  should  be  removed 
at  once  will  be  determined  by  the  condition  of  the  patient  and  the 
manner  in  which  he  bears  the  operation.  As  a  general  thing  there  is 
no  harm  in  removing  all  the  fluid,  provided  it  is  not  evacuated  too 
rapidly. 

Position  of  Patient. — The  patient  should  sit  upright  on  the  edge 
of  the  bed,  if  possible,  or,  if  unable  to  do  this,  he  may  lie  propped  up 
in  a  semirecumbent  position  so  as  to  favor  gravitation  of  the  fluid  to 


Fig.  299. — Aspiration  of  the  peritoneal  cavity.     First  step,  application  of  the 
*  abdominal  binder. 


the  lowest  level  of  the  peritoneal  cavity.  When  the  puncture  is  made 
in  the  linea  semilunaris,  the  patient  should  lie  upon  the  side  on  which 
the  puncture  is  made. 

Preparations. — Tlie  bladder  and  bowels  should  always  be  empty 
before  operation.  The  abdominal  wall  is  shaved  and  the  site  of  punc- 
ture is  painted  with  tincture  of  iodin.  The  operator's  hands  should 
likewise  be  sterilized,  and  the  trocar  is  to  be  boiled. 

Anesthesia. — Local  anesthesia  with  ethyl  chlorid,  ether,  ice  and 
salt,  or  infiltration  with  a  few  drops  of  a  0.2  per  cent,  solution  of 
cocain  or  a  i  per  cent,  solution  of  novocain  may  be  used. 

Technic. — A  broad  abdominal  binder,  or  a  Scultetus  bandage 
with  a  central  slit  corresponding  to  the  point  where  the  trocar  is  to  be 
introduced,  is  first  fitted  about  the  patient's  abdomen  (Fig.  299)  and 


ASPIRATION   FOR  ASCITES 


299 


is  to  be  tightened  at  intervals  during  the  operation,  so  that  uniform 
pressure  may  be  appKed  while  the  fluid  is  flowing  off  and  a  sudden 
overfilling  of  the  abdominal  vessels  with  blood  prevented.  With  a 
scalpel  the  skin  is  incised  for  a  distance  of  1/4  inch  (6  mm.)  at  the 
spot  chosen  for  the  puncture  (Fig.  300),  and  the  trocar  is  slowly  and 
steadily  inserted,  with  the  index  finger  held  along  the  instrument  as 
a  guide  to  the  depth  it  is  to  enter,  and  to  prevent  it  from  being  sud- 
denly forced  in  too  far  (Fig.  301).  As  soon  as  it  is  judged  that  the 
peritoneal  cavity  has  been  reached,  the  trocar  is  withdrawn  and  the 
fluid  is  permitted  to  escape. 


Fig.  300. — Aspiration  of  the  peritoneal  cavity.     Second  step,  nicking  the  skin  at 

the  point  of  puncture. 


The  fluid  should  be  evacuated  slowly,  and,  if  it  flows  too  freely, 
it  is  well  to  stop  the  flow  at  intervals  by  placing  the  finger  over  the 
end  of  the  trocar,  in  order  to  allow  the  abdominal  contents  to  adapt 
themselves  to  the  changed  conditions.  If  the  stream  is  suddenly 
stopped  by  the  intestines  or  omentum  occluding  the  end  of  the  instru- 
ment, a  slight  turn  of  the  cannula  or  a  change  in  its  position  may  be 
suf&cient  to  reheve  the  obstruction;  if  not,  it  may  be  necessary  to 
clear  the  lumen  by  passing  a  sterile  probe  through  it.  As  the  fluid 
is  withdrawn,  and  the  distention  of  the  abdomen  decreases,  neces- 
sary support  is  given  to  the  lax  abdominal  walls  by  drawing  the 
binder  tighter.     Syncope  may  be  thus  avoided;  should  it  occur,  how- 


300 


ASPIRATIONS 


ever,  the  escape  of  the  fluid  must  be  temporarily  stopped  by  placing 
the  finger  over  the  end  of  the  trocar  and  the  patient's  head  must  be 
lowered,  care  being  taken  to  see  that  air  does  not  enter  the  trocar 
while  this  is  being  done. 

When  fluid  ceases  to  flow,  the  cannula  is  quickly  removed  and, 
if  a  large  opening  has  been  made  by  the  trocar,  the  skin  may  be 
drawn  together  by  a  subcutaneous  stitch  and  the  line  of  incision 
sealed  with  collodion  and  cotton.  If  there  seems  to  be  a  good  deal 
of  oozing  of  fluid  along  the  track  of  the  trocar,  however,  a  sterile 


Fig.  301. — Aspiration  of  the  peritoneal  cavitj'-.     Third  step,  showing  the  method  of 

inserting  the  trocar. 

gauze  dressing,  held  in  place  with  rubber  adhesive  plaster  and 
changed  as  often  as  necessary,  will  be  found  more  satisfactory. 
After  the  aspiration  the  patient  should  be  kept  in  bed  for  at  least 
twenty-four  hours. 

ASPIRATION  OF  THE  TUNICA  VAGINALIS 

This  operation  is  employed  for  the  cure  of  hydrocele.  It  consists 
in  introducing  an  aspirating  needle  or  trocar  and  cannula  into  the 
tunica  vaginalis  and  removing  the  contained  fluid.  It  may  be  per- 
formed simply  to  withdraw  the  hydrocitic  fluid  or  as  part  of  the 
radical  cure  by  injection  of  carbohc  acid.  The  former  is  rarely  more 
than  a  palliative  measure,  as  the  fluid  usually  promptly  recurs. 


ASPIRATION    OF    THE    TUXICA   VAGINALIS 


301 


The  treatment  by  a  combination  of  aspiration  and  the  injection 
of  95  per  cent,  carbolic  acid  is,  however,  successful  in  more  than  80 
per  cent,  of  cases  (Bevan).  It  is  especially  applicable  to  hydroceles 
with  thin  sacs;  in  the  old,  chronic  cases  with  thick  sacs  it  is  not  often 
successful. 

The  operation  is  practically  without  danger,  if  performed  with 
proper  technic  and  care  is  taken  to  prevent  injury  to  the  structures 


Fig.  302. — Trocar  and  syringe  for  aspirating  and  injecting  a  hydrocele. 

of  the  cord  and  the  testicle.  The  latter  usually  lies  posterior  to 
the  tumor,  though  in  rare  cases  it  may  be  in  front.  Its  position 
should  always  be  ascertained  first,  if  possible,  by  palpation  and 
transillumination. 

Instruments. — A  medium  size  trocar  and  cannula,  or  a  large 
aspirating  needle,  to  which  may  be  attached  a  small  aspirating 
syringe,  will  be  required  (Fig.  302). 


Pig.  303. — Aspirating  a  hydrocele.     Showing  the  method  of  grasping  the  scrotum 
and  the  trocar  being  inserted. 

Site  of  Puncture. — The  trocar  should  be  introduced  at  the  junc- 
tion of  the  lower  and  middle  thirds  of  the  anterior  surface  of  the 
scrotum,  at  a  spot  where  visible  blood-vessels  are  scarce. 

Asepsis. — The  usual  aseptic  precautions  should  be  observed. 
The  skin  at  the  site  of  puncture  should  be  shaved  and  then  painted 


302 


ASPIRATIONS 


with  tincture  of  iodin.     The  operator's  hands  should  be  prepared 
as  for  any  operation,  and  the  instruments  boiled. 

Anesthesia. — The  spot  of  intended  puncture  may  be  anesthetized 


Fig.  304. — Aspirating  a  hydrocele.     Showing  the  cannula  in  place. 

by  the  injection  of  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain,  or  frozen  by  ethyl  chlorid. 

Technic. — The  operator  places  his  left  hand  behind  the  scrotum 


Fig.  305. — Method  of  injecting  a  hydrocele. 

and  grasps  the  neck  of  the  hydrocele  between  the  thumb  and  fore- 
finger, thus  making  the  tumor  tense  by  compression.  Holding  the 
trocar  and  cannula  in  the  right  hand  with  the  index  finger  placed 


ASPIRATION    OF   THE   TUNICA  VAGINALIS  303 

about  I  inch  (2.5  cm.)  from  its  tip  so  as  to  prevent  the  instrument 
being  introduced  too  deeply,  the  operator  thrusts  it  into  the  tunica 
vaginaHs  in  an  upward  and  backward  direction  (Fig.  303).  As  soon 
as  the  trocar  enters  the  sac,  indicated  by  a  lack  of  resistance  to  its 
further  progress,  the  point  of  the  instrument  is  turned  upward  thus 
depressing  the  free  end  and  the  trocar  is  removed  (Fig.  304).  All  the 
fluid  is  then  allowed  to  escape,  and,  to  make  sure  the  sac  is  empty, 
the  aspirator  may  be  attached  and  suction  employed. 

The  cannula  is  left  in  site  and  from  5  to  30  drops  (0.3  to  2  c.c.) 
of  95  per  cent,  (deliquescent)  carbolic  acid,  depending  upon  the  size 
of  the  hydrocele,  are  injected  through  the  cannula  (Fig.  305).  If  a 
syringe  cannot  be  attached  directly  to  the  cannula,  the  injection  may 
be  made  by  means  of  a  hypodermic  syringe  and  a  long  needle  in- 
serted through  the  cannula.  The  skin  is  then  pinched  up  around  the 
cannula,  which  is  quickly  removed,  and  the  scrotum  is  manipulated 
so  as  to  smear  the  acid  over  the  whole  interior.  The  puncture  is 
then  finally  sealed  with  collodion  and  cotton. 

The  patient  should  remain  in  bed  twenty-four  to  forty-eight  hours 
after  the  operation  with  a  supporting  dressing  applied  to  the  scrotum. 
Some  swelling  follows  the  injection,  but  it  usually  subsides  within  a 
week  or  ten  days.  During  this  time  the  patient  should  wear  a 
well-fitting  suspensory. 

ASPIRATION  OF  THE  BLADDER 

Aspiration  of  the  bladder  will  be  considered  under  the  section 
devoted  to  that  organ  (see  page  692). 


CHAPTER  XIII 
THE  NOSE  AND  ACCESSORY  SINUSES 

Anatomic  Considerations 

The  Nose. — For  purposes  of  description  the  nose  is  divided  into 
an  external  and  an  internal  portion. 

The  external  nose  forms  a  prominence  upon  the  face  resembling  a 
triangular  pyramid,  made  up  chiefly  of  bone  and  cartilage  and 
covered  with  muscles  and  integument.  The  bony  portion,  or  bridge, 
is  composed  of  the  nasal  portions  of  the  superior  maxilla  and  the  two 
nasal  bones.  The  arch  forming  the  forepart  of  each  side  of  the  nose 
is  composed  of  two  large  lateral  cartilages  which  converge  to  form  the 
ridge  and  tip.  These  are  supplemented  usually  by  three  smaller 
cartilages  bound  together  by  connective  tissue,  which  aid  in  forming 
the  wings  or  alae. 

The  interior  of  the  nose  is  divided  by  the  septum  into  two  cham- 
bers, or  fossae,  narrow  above  and  more  expanded  below.  These 
open  anteriorly  by  the  anterior  nares,  two  pear-shaped  apertures 
measuring  about  i  inch  (2.5  cm.)  vertically  and  1/2  inch  (i  cm.) 
transversely  at  their  widest  points.  Posteriorly,  the  nasal  fossae 
communicate  with  the  nasopharynx  by  two  corresponding  openings, 
the  posterior  nares.  Each  fossa  also  communicates  with  air  spaces 
situated  in  the  frontal,  ethmoid,  sphenoid,  and  superior  maxillary 
bones.  The  roof  is  formed  by  the  nasal  bones,  the  cribriform  plate 
of  the  ethmoid,  and  the  body  of  the  sphenoid.  The  floor,  concave 
from  side  to  side,  is  formed  by  the  palatal  process  of  the  superior 
maxilla  and  the  horizontal  process  of  the  palate  bones.  It  separates 
the  nose  from  the  mouth.  The  inner  wall,  or  septum,  is  formed 
posteriorly  by  the  perpendicular  plate  of  the  ethmoid  and  the  vomer, 
and  anteriorly  by  the  triangular  cartilage.  The  septum  is  seldom 
exactly  in  the  median  line,  but  is  usually  more  or  less  deflected,  so 
that  it  is  unusual  to  find  the  two  fossae  of  equal  size.  The  outer  walls 
of  the  nose  are  formed  by  the  superior  maxillary,  the  lachrymal,  the 
ethmoid,  the  palate,  and  the  sphenoid  bones.  They  are  very  irreg- 
ular, due  to  the  presence  of  the  turbinate  bodies  which  project  into 
the  fossae  and  partly  divide  them  into  three  separate  recesses,  the 
superior,  the  middle,  and  the  inferior  meatus  (Fig.  306). 

304 


ANATOMIC    CONSIDERATIONS 


305 


The  superior  meatus  lies  between  the  superior  and  middle  turbi- 
nates. It  is  narrow  and  groove-like,  and  is  the  smallest  of  the  three. 
The  orifices  of  the  posterior  ethmoidal  cells  open  upon  the  upper  and 
forepart  of  its  outer  wall. 


Fig.  306 — Transverse  section  of  the  nasal  cavities.     (After  Zuckerkandl.) 

The  middle  meatus  lies  between  the  middle  and  inferior  turbinates, 
and  is  more  capacious  than  the  superior,  extending  along  the  pos- 
terior two-thirds  of  the  outer  wall  of  the  nose.  Opening  into  the 
middle  meatus  on  the  outer  wall  is  a  crescentic  slit-like  aperture, 


Fig.  307. — Showing  the  structures  in  the  outer  wall  of  the  nasal  cavity.  1, 
Opening  of  the  sphenoidal  sinus;  2,  superior  meatus;  3,  middle  meatus;  4,  inferior 
meatus. 


the  hiatus  semilunaris.  Just  above  it,  and  at  times  partly  occluding 
this  opening,  is  a  protuberance,  the  bulla  ethmoidalis,  which  marks 
the  situation  of  the  anterior  ethmoidal  cells.  Upon  the  lateral  wall  of 
the  middle  meatus  and  extending  from  the  hiatus  semilunaris  upward 


3o6 


THE   NOSE    AND   ACCESSORY   SINUSES 


and  forward,  is  a  curved  groove  bounded  internally  by  the  uncinate 
process  of  the  ethmoid,  known  as  the  infundibulum.  From  this  a 
closed  duct  leads  into  the  frontal  sinus.  At  the  deepest  portion  of 
the  infundibulum  near  the  posterior  end,  is  the  opening  of  the  max- 
illary sinus,  and  behind  this  at  times  is  found  an  accessory  opening. 
The  anterior  ethmoidal  cells  also  open  into  the  infundibulum  on  the 
upper  part  of  the  outer  wall  or  else  they  communicate  with  the 
frontonasal  duct. 

From  the  anatomical  relation  of  these  openings,  it  can  be  under 
stood  how  readily  infection  of  the  maxillary  sinus  may  follow  a  sup- 
purative condition  of  the  anterior  ethmoidal  cells  or  frontal  sinus 


Fig.  308. — Lateral  wall  of  the  right  nasal  cavity  showing  the  orifices  of  the 
accessory  sinuses.  (After  Schultze  and  Stewart.)  The  dotted  line  indicates  the 
outline  of  the  Aiiddle  turbinate,  which  has  been  removed  to  show  the  structures 
beneath.  A  portion  of  the  inferior  turbinate  has  also  been  removed,  i,  Frontal 
sinus;  2,  infundibulum;  3,  hiatus  semilunaris;  4,  orifice  of  the  nasal  duct;  5,  bulla 
ethmoidalis;  6,  inferior  turbinate;  7,  accessory  orifice  of  the  maxillary  sinus;  8, 
orifice  of  Eustachian  tube;  9,  fossa  of  Rosenmiiller;  10,  sphenoidal  sinus;  11, 
orifice  of  the  sphenoidal  sinus;  12,  orifice  of  the  middle  and  posterior  ethmoidal 
cells;   13,  orifice  of  the  anterior  ethmoidal  cells. 


discharges  from  the  latter  being  very  apt  to  find  their  way  into  the 
ostium  of  the  maxillary  sinus. 

The  inferior  meatus,  the  largest  of  the  three,  lies  between  the 
inferior  turbinate  bone  and  the  floor  of  the  nasal  cavity,  extending 
along  the  entire  length  of  the  outer  wall  of  the  nose.  The  nasal  duct, 
leading  from  the  orbit,  opens  into  the  inferior  meatus  at  the  junction 
of  the  anterior  third  with  the  posterior  two-thirds. 

The  mucous  membrane  lining  the  nasal  cavity  is  continuous 
anteriorly  with  the  integument  and  also  with  the  mucous  membrane 
of  the  pharynx,  Eustachian  tubes,  and  accessory  sinuses.     In  the 


ANATOMIC   CONSIDERATIONS 


307 


upper  portion  of  the  nose  the  mucous  membrane  is  of  the  columnar 
variety.  In  this  region  it  is  thin  and  closely  bound  to  the  perios- 
teum and  perichondrium  beneath,  and  contains  the  endings  of  the 
olfactory  nerves.  The  remainder  of  the  nasal  cavity  is  lined  with 
ciliated  epithelium.  Over  the  inferior  turbinates,  the  lower  portion 
of  the  middle  turbinates,  and  corresponding  parts  of  the  septum  the 
mucous  membrane  is  thick  and  very  vascular,  containing  numerous 
thin-walled  venous  channels  capable  of  becoming  so  enormously  dis- 
tended with  blood  that  they  may  even  occlude  the  nares.  On  the 
floor  of  the  nose  the  mucous  membrane  again  becomes  thinned  out. 
The  Accessory  Sinuses.— Hollowed  out  of  the  bones  surround- 
ing the  nasal  foss£e  are  four  cavities  filled  with  air,  known  as  the 
maxillary,  frontal,  ethmoid,  and  sphenoid  sinuses.     These  accessory 


Fig.  309. — Cross-section  of  the  maxillary  sinuses,  showing  the  close  relation  of  the 
roots  of  the  molar  teeth  to  the  floors  of  the  sinuses.      (After  Zuckerkandl.) 

sinuses  are  lined  with  a  thin,  pale,  mucous  membrane  continuous 
with  that  of  the  meatus  into  which  each  sinus  respectively  opens. 
The  function  of  the  sinuses  is  to  give  resonance  to  the  voice  and  at 
the  same  time  add  to  the  lightness  of  the  skull. 

The  maxillary  sinus  or  antrum  of  Highmore,  lies  to  the  outer  side 
of  the  nasal  fossa,  occupying  the  greater  portion  of  the  superior  max- 
illary bone.  It  is  the  largest  of  all  the  accessory  sinuses.  In  shape 
it  resembles  a  three-sided  pyramid,  with  the  apex  at  the  zygomatic 
process  of  the  maxilla,  and  the  base  directed  toward  the  nasal  cavity. 
The  roof  of  the  antrum  is  very  thin  and  forms  the  floor  of  the  orbit. 
The  anterior  wafl  is  directed  toward  the  face  and  corresponds  to  the 
canine  fossa  externally.  The  floor,  which  is  directed  toward  the 
mouth,  is  formed  by  the  alveolar  margin  and  outer  portion  of  the  hard 


3o8  THE   NOSE   AND   ACCESSORY   SINUSES 

palate.  The  roots  of  the  molar  teeth  almost  protrude  through  the 
floor  into  the  antrum  (Fig.  309),  being  often  separated  from  the  cavity 
by  a  thin  shell  of  bone,  or  merely  mucous  membrane,  so  that  ulcera- 
tion of  the  teeth  may  readily  lead  to  infection  of  the  sinus.  This 
anatomical  arrangement  is  sometimes  taken  advantage  of  in  draining 
the  antrum,  a  tooth  being  extracted  and  the  sinus  opened  through 
the  alveolus. 

Ordinarily,  the  antrum  has  a  capacity  of  about  4  drams  (15  c.c), 
but  its  size  varies  greatly,  and  in  the  same  individual  the  two  sides 
are  frequently  disproportionate.  The  antrum  communicates  with  the 
middle  meatus  by  an  ostium  opening  into  the  infundibulum,  and 
thence  through  the  hiatus  semilunaris.  This  aperture  cannot  be 
seen  until  the  middle  turbinate  has  been  removed.  In  a  small  per- 
centage of  cases  an  accessory  ostium  is  found  lying  posterior  to  the 
main  opening. 

The  Frontal  Sinus. — The  frontal  sinuses  are  two  air  spaces  sepa- 
rated from  each  other  by  a  septum,  lying  between  the  tables  of  the 
frontal  bone  above  the  orbits.  Each  consists  of  a  vertical  portion 
passing  upward  on  the  forehead  and  a  horizontal  portion  extending 
backward  over  the  roof  of  the  orbit.  Their  size  is  variable  and  they 
are  often  unequal  through  deflection  of  the  septum  to  one  side. 
Cases  have  been  observed  with  one  sinus  entirely  absent.  The  floor 
of  the  sinus  forms  by  its  external  portion  the  roof  of  the  orbit,  and  by 
its  inner  portion  the  roof  of  some  of  the  anterior  ethmoidal  cells. 
The  latter  part  of  the  floor  is  extremely  thin,  so  that  suppuration  of 
the  frontal  sinus  is  liable  to  extend  to  the  anterior  ethmoidal  cells. 
The  posterior  wall  separates  the  sinus  from  the  frontal  lobes  of  the 
brain  by  an  extremely  thin  plate  of  bone.  The  anterior  wall  is  thick 
and  is  represented  externally  by  the  superciliary  ridge.  In  the 
posterior  portion  of  the  floor  of  the  sinus  is  the  rounded  or  oval 
aperture  leading  into  the  infundibulum  and  thence  to  the  middle 
meatus  by  means  of  the  hiatus  semilunaris. 

The  ethmoidal  cells  lie  in  the  lateral  masses  of  the  ethmoid  bone. 
These  cells  vary  in  size  and  number.  They  are  divided  into  two 
sets,  anterior  and  posterior.  The  anterior  open  into  the  middle 
meatus,  generally  by  the  infundibulum,  while  the  posterior  set 
open  into  the  superior  meatus.  These  cells  are  separated  from  the 
cranial  cavity  and  orbit  by  extremely  thin  plates  of  bone. 

The  sphenoidal  cells  are  situated  in  the  body  of  the  sphenoid  bone 
close  to  the  base  of  the  skull.  They  are  quadrilateral  in  shape  and 
variable  in  size,  and,  like  the  frontal  sinuses,  they  may  be  asymmetri- 


RHINOSCOPY  309 

cal  from  deviation  of  the  septum.  The  anterior  wall  looks  downward 
and  forward  and  forms  a  part  of  the  roof  of  the  nasal  cavity.  The 
upper  wall  is  very  thin  and  separates  the  sinus  from  the  cranial 
cavity.  The  cells  communicate  with  the  nasal  cavity  through  an 
opening  situated  above  and  behind  the  superior  turbinate. 

Diagnostic  Methods 

Prior  to  making  an  internal  examination  of  the  nasal  cavities, 
careful  notes  should  be  taken  of  the  patient's  history  and  symptoms, 
for  future  reference,  and  a  thorough  inspection  should  be  made  of  the 
external  nose.  On  general  inspection  one  should  note  the  shape  of 
the  nose,  with  reference  to  signs  of  cretinism,  s^^hilis.  new  growths, 
deviations,  or  deformities.  The  shape  of  the  jaws  also  should  be 
observed;  likewise  the  presence  or  absence  of  any  prominences  or 
bulging  in  the  neighborhood  of  the  accessory  sinuses;  the  presence  or 
absence  of  enlarged  cervical  glands;  the  presence  of  excoriations, 
herpes,  or  crusts  about  the  anterior  nares  and  upper  lip,  as  indica- 
tions of  nasal  discharge.  It  should  be  ascertained  whether  the  patient 
breathes  through  the  mouth,  and  the  patency  of  the  nose  should  be 
tested  by  alternately  closing  each  nostril  with  the  finger  while  the 
patient  breathes  through  the  opposite  one.  The  odor  of  the  breath, 
the  presence  or  absence  of  marked  movement  of  the  al^  nasi,  or  any 
sounds  produced  during  nasal  breathing,  and  the  character  of  the 
voice  should  also  be  carefully  noted.  Having  completed  this  pre- 
liminary examination,  that  of  the  interior  of  the  nose  may  be  pro- 
ceeded with. 

For  an  examination  of  the  nasal  caA^ty  and  accessory  sinuses 
five  methods  are  available:  namely,  (i)  inspection  or  rhinoscopy; 
(2)  probing;  (3)  palpation;  (4)  transillumination;  and  (5)  skiagraphy. 

RHINOSCOPY 

Inspection  of  the  interior  of  the  nose  may  be  performed  by 
anterior  and  by  posterior  rhinoscopy.  In  anterior  rhinoscopy  the 
examination  is  made  through  the  anterior  nares  with  the  aid  of  a 
suitable  speculum  and  a  strong  light.  Posterior  rhinoscopy  consists 
in  an  examination  of  the  nose  from  within  the  pharynx  by  the  aid 
of  reflected  light  and  a  rhinoscopic  or  small  laryngeal  mirror.  The 
former  is  simple  and  requires  no  great  skill,  but  the  latter  is  by  no 
means  an  easy  procedure  for  one  not  specially  trained,  and  at  times 


3IO 


THE   NOSE    AND   ACCESSORY   SINUSES 


requires  considerable  patience  on  the  part  of  the  operator  to  com- 
plete successfully  and  satisfactorily. 

Illumination. — To  obtain  a  satisfactory  view  of  the  interior  of  the 
nose,  it  is  necessary  to  have  good  illumination.  Strong  sunlight 
may  be  utilized  for  anterior  rhinoscopy,  but  it  is  not  suitable  for  an 
examination  of  the  posterior  nares.  A  Welsbach  burner  fitted  with  a 
mica  chimney  over  which  is  placed  a  Mackenzie  condenser  gives 
excellent  illumination  (Fig.  310).  Electric  light  from  a  frosted 
lamp  is  also  much  used  and  has  an  advantage  in  that  it  does  not 
give  out  much  heat. 


Fig.  310. — Gas  lamp  upon  an  adjustable  stand  fitted  with  a  Mackenzie  condenser. 


Whatever  the  form  of  light,  it  should  be  so  arranged  upon  a 
suitable  bracket  that  it  may  be  raised,  lowered,  or  turned  from  side 
to  side  without  inconvenience  to  the  operator.  The  light  should  be 
placed  upon  the  patient's  right,  somewhat  behind  him,  and  about 
on  a  level  with  the  tip  of  his  ear. 

Many  operators  prefer  an  illumination  furnished  by  an  electrical 
head  light  (Fig.  311).  Such  a  light,  with  the  current  furnished  from 
a  small  pocket  storage  battery  will  be  found  a  great  convenience 
outside  the  examining  room. 


RHINOSCOPY 


311 


Instruments.— In  addition  to  a  suitable  light,  there  will  be  re- 
quired: a  concave  head  mirror,  about  3  1/2  to  4  inches  (9  to  10  cm.) 
in  diameter,  with  a  large  central  eye-hole,  and  secured  to  a  soft 
leather  headband  by  a  bah-and-socket  joint;  a  rhinoscopic  mirror 


Fig.  311. — Electric  head  light. 


YiG,  312.— Instruments  for  rhinoscopy,  i,  Alcohol  lamp;  2,  rhinoscopic 
mirror;  3,  White's  palate  retractor;  4,  Myles'  nasal  speculum;  5,  head  mirror; 
6,  nasal  appUcator;  7,  Fraenkel's  tongue  depressor. 

1/2  inch  (i  cm.j  m  diameter,  set  at  an  angle  of  100  to  no  degrees 
with  the  shaft,  which  is  curved  to  follow  the  Hne  of  the  tongue;  a 
Myles  soUd-blade  nasal  speculum;  a  Fraenkel  tongue  depressor;  a 
White  palate  retractor;  and  a  nasal  appKcator  with  a  triangular- 
tipped  shaft  (Fig.  312). 


312 


THE   NOSE   AND   ACCESSORY   SINUSES 


Asepsis. — Instruments,  such  as  tongue  depressors,  specula, 
applicators,  etc.,  may  be  sterilized  by  boiling.  The  rhinoscopic 
mirrors,  however,  which  are  soon  destroyed  by  boiling,  may  be 
sterilized  by  immersion  in  a  solution  of  i  to  20  carbolic  acid  and 
then  wiped  dry  before  using. 

Position  of  the  Patient. — The  patient  is  seated  upright  upon  a 
firm,  straight-backed  chair.  The  examiner  sits,  facing  the  patient, 
upon  an  adjustable  seat,  such  as  a  piano  stool,  which  may  be  readih- 
raised  or  lowered  according  to  the  height  of  the  patient. 

Technic. — i.  Anterior  Rhinoscopy. — The  operator  adjusts  the 
head  mirror  in  such  a  way  that  the  central  opening  is  opposite  his 
left  eye  and  the  light  is  reflected  into  the  nostrils  of  the  patient.  The 
outline  of  the  anterior  nares  is  then  brought  into  view,  and  the 
relative  size  of  the  two  fossae  may  be  appreciated.  Care  should  be 
taken  to  look  for  fissures,  abrasions,  or  pimples  on  the  inner  surface 


Fig.  313. — Myles'  speculum  in  place. 

of  the  vestibule  of  the  nose,  contact  with  which  would  make  the  in- 
troduction of  the  speculum  painful,  without  preliminary  cocainiza- 
tion.  The  speculum  is  then  introduced  with  the  blades  closed,  and, 
upon  sliding  them  apart,  the  necessary  amount  of  dilatation  is  ob- 
tained (Fig.  313). 

The  inspection  of  the  cavity  should  proceed  from  before  backward, 
the  Ught  being  thrown  into  all  recesses.  By  slightly  elevating  the 
tip  of  the  nose,  the  floor  of  the  nose,  the  inferior  turbinate,  and  the 
inferior  meatus  are  brought  to  view.  In  some  cases  where  the  nose 
is  very  broad  or  the  inferior  turbinate  small  or  shrunken,  it  may  even 
be  possible  to  see  as  far  back  as  the  posterior  wall  of  the  nasopharynx. 
By  bending  the  patient's  head  backward  and  raising  the  chin,  the 


RHINOSCOPY 


313 


middle  meatus  and  the  middle  turbinate  may  be  seen;  only  when  the 
latter  has  been  removed,  or  is  very  much  atrophied,  however,  is  it 
possible  to  obtain  a  view  of  the  apertures  leading  to  the  accessory 
sinuses.  Tilting  the  patient's  head  still  further  backward  exposes 
to  view  the  upper  portion  of  the  middle  turbinate  and  the  roof  of  the 
nose.  Occasionally  the  opening  of  the  sphenoidal  sinus  may  be 
made  out,  but  only  in  exceptional  cases  is  it  possible  to  see  the 
superior  turbinate. 

By  the  direct  application  of  cocain  or  adrenalin  to  the  mucous 
membrane  with  cotton  pledgets  or  by  spraying,  the  membrane  may 


Fig.  314. — Showing  the  method  of  performing  anterior  rhinoscopy. 


be  caused  to  shrink  and  a  more  satisfactory  view  of  the  structures 
within  the  nose  may  be  obtained.  This  is  especially  useful  where  the 
nasal  cavity  is  narrow  or  the  turbinates  are  hypertrophied. 

Secretions  that  obstruct  the  view  are  gently  wiped  away  by 
means  of  a  cotton-wrapped  nasal  probe  or  applicator.  The  appear- 
ance and  general  condition  of  the  mucous  membrane  are  thus  in- 
spected and  the  apparent  source  of  any  discharge  noted.  In  general, 
pus  in  the  middle  meatus  means  that  the  frontal  or  maxillary  sinus 
or  anterior  ethmoidal  cells  are  involved,  as  they  all  drain  into  this 
recess;  while  a  discharge  seen  in  the  space  between  the  middle  tur- 
binate and  septum  signifies  infection  of  either  the  sphenoidal  or  pos- 


314 


THE   NOSE   AND   ACCESSORY   SINUSES 


terior  ethmoidal  cells.  To  ascertain  exactly  which  sinus  is  involved, 
frequently  other  aids  to  diagnosis,  as  probing,  transillumination,  or 
skiagraphy,  must  be  employed. 

The  attention  of  the  examiner  is  fmally  directed  to  the  bony  and 
cartilaginous  portions  of  the  nose.  Deviations,  ulcerations,  perfora- 
tions, and  spurs  of  the  septum,  contracture  or  hypertrophy  of  the 
turbinal  bodies,  the  presence  of  foreign  bodies,  the  presence  of  new 
growths  and  their  point  of  attachment,  etc.,  etc.,  are  in  a  general 
way  the  conditions  to  be  looked  for. 

2.  Posterior  Rhinoscopy. — The  operator  adjusts  the  head  mirror 
over  his  left  eye  so  that  the  light  is  thrown  upon  the  patient's  mouth. 
The  patient  is  instructed  to  open  the  mouth,  and  a  tongue  depressor 


Fig.  315. — First  step  in  posterior  rhinoscopy,  inserting  the  tongue  depressor 


held  between  the  thumb  and  the  index  and  middle  fingers  of  the  left 
hand,  is  inserted  and  passed  over  the  dorsum  of  the  tongue  until  the 
tip  of  the  instrument  rests  just  behind  its  arch.  The  tongue  is  then 
drawn  downward  and  forward  into  the  floor  of  the  mouth  (Fig. 
315).  If  care  be  taken  not  to  insert  the  depressor  too  far  and  to  avoid 
pushing  back  on  the  tongue,  gagging  will  be  prevented.  A  mirror  of 
suitable  size  is  then  warmed  and,  with  the  light  reflected  upon  the 
posterior  pharyngeal  wall,  the  mirror  is  gently  introduced  into  the 


RHINOSCOPY 


3^5 


mouth,  lightly  held  between  the  thumb  and  forefinger  of  the  right 
hand  with  its  metal  surface  directed  toward  the  tongue.  The  mirror 
should  then  be  carefully  carried  back  into  the  nasopharynx,  avoiding 
the  back  of  the  tongue,  the  palate,  and  uvula.  After  the  instru- 
ment has  entered  the  nasopharyngeal  space,  a  clear  view  of  the  pos- 
terior ends  of  the  turbinates  and  the  other  postnasal  structures  will 
be  obtained  by  depressing  the  handle  of  the  instrument  sHghtly  so 
that  the  upper  border  of  the  mirror  lies  behind  the  soft  palate.  At 
the  same  time,  the  handle  of  the  mirror  should  be  so  held  toward 
the  left  angle  of  the  patient's  mouth  that  illumination  is  not  interfered 
with  (Fig.  316). 


Fig.  316. 


Fig.  317. 


Fig.  316. — Showing  the  rhinoscopic  mirror  in  place. 

Fig.  317. — Posterior  rhinoscopic  image,  i,  Roof  of  pharynx;  2  uvula;  3 
soft  palate;  4,  opening  of  Eustachian  tube;  5,  superior  turbinate;  6,  middle  tur- 
binate; 7,  inferior  turbinate. 

It  should  be  remembered  that  it  is  not  possible  to  obtain  a  view  of 
the  whole  postnasal  space  at  one  time,  but,  on  turning  the  mirror  in 
various  directions  by  rotating  its  handle,  different  portions  may  be 
brought  into  view  and  the  entire  space  may  thus  be  examined  in 
detail.  By  first  holding  the  handle  of  the  instrument  well  up,  the 
vault  of  the  pharynx  will  be  brought  into  view,  and  the  presence  or 
absence  of  adenoids  or  other  tumors  may  be  ascertained.  The 
pharyngeal  vault  is  usually  smooth  and  dome-shaped,  but  it  may  be 
almost  completely  filled  up  and  show  depressions  and  elevations 
depending  on  the  size  and  condition  of  the  pharyngeal  tonsil.  On 
depressing  the  handle  slowly,  the  posterior  nares  may  be  examined 


3i6 


THE   NOSE   AND   ACCESSORY    SINUSES 


in  detail  from  above  downward.  In  the  median  line  is  seen  the 
septum;  on  either  outer  wall  from  above  downward  will  be  seen  the 
ridge  of  the  superior  turbinate,  w4th  the  superior  meatus  lying  just 
below  as  a  darkened  depression.  Below  this  wdll  be  observed  the 
middle  turbinate  as  a  pinkish-white  fusiform  body,  and,  underlying 
this,  the  middle  meatus.  The  inferior  turbinate  appears  just  below 
this  as  a  grayish- white  body.  Finally,  by  turning  the  mirror  to  either 
side,  the  orifices  of  the  Eustachian  tubes  and  the  Eustachian  cushions 
are  brought  to  view.  Care  should  be  taken  not  to  keep  the  mirror 
in  the  throat  too  long  or  the  patient  will  be  tired  out;  to  make  a 
complete  examination,  it  is  better  to  reinsert  it  more  than  once  if 
necessary. 


Fig.  318. — White's  palate  retractor  in  place. 

In  some  cases  it  may  be  almost  an  impossibility  to  make  a  satisfac- 
tory posterior  rhinoscopic  examination.  This  may  be  from  the  forma- 
tion of  the  parts,  as,  for  example,  in  the  presence  of  a  hard  palate 
which  extends  so  far  back  that  there  is  no  room  for  the  mirror,  or  a 
broad  soft  palate  w^ith  a  long  uvula,  or  it  may  be  due  to  the  presence  of 
a  growth  in  the  nasopharynx.  The  most  common  obstacle,  however, 
is  the  involuntary  elevation  of  the  soft  palate  on  the  introduction  of 
the  mirror,  so  that  the  view  of  the  parts  above  is  blocked.  Instructing 
the  patient  to  breathe  through  the  nose  with  the  mouth  open,  or  to 
pronounce  "en"  with  strong  nasal  sound,  often  suffices  to  overcome 
this  impediment.     In  other  cases  it  will  be  necessary  to  use  a  palate 


IXSPECTIOX    OF    THE    NASOPHARYNX 


317 


retractor,  such  as  White's.  After  applying  cocain  to  the  soft  palate, 
the  wire  palate  loop  of  the  instrument  is  passed  behind  the  soft  palate 
and  the  stem  of  the  instrument  so  adjusted  as  to  draw  the  palate  well 
forward  into  the  desired  position.  The  instrument  is  maintained  in 
position  by  means  of  the  wire  loops  which  rest  wdthin  the  nose 
(Fig.  318). 


INSPECTION  OF  THE  NASOPHARYNX  BY  MEANS  OF  THE 
HAYS  PHARYNGOSCOPE 

To  overcome  the  difficulties  encountered  in  examining  the  naso- 
pharynx with  a  rhinoscopic  mirror,  Hays  has  devised  an  instrument 
made  on  the  plan  of  an  indirect  view  cystoscope,  which  he  calls  the 
pharyngoscope.^  With  this  instrument,  the  use  of  which  requires 
none  of  the  skill  necessary  for  the  ordinary  posterior  rhinoscopic 


Fig.  319. — Hays'  phan'^ngoscope. 

examination,  it  is  possible  to  obtain  a  clear  picture  of  tne  nasopharynx, 
posterior  nares,  Eustachian  tubes,  as  well  as  the  larynx  without 
the  slightest  discomfort  to  the  patient.  Furthermore,  as  the  various 
structures  are  brought  to  view  they  may  be  inspected  in  a  very 
systematic  and  thorough  manner  and  with  the  avoidance  of  any  haste, 
as  the  instrument,  once  inserted,  may  be  left  in  place  anywhere  from 
five  to  twenty  minutes,  during  which  time  its  position  need  not  be 
changed. 

Instruments. — All  that  is  required  is  the  pharyngoscope  and  a  six- 
dry-cell  battery.  The  instrument  is  made  in  the  form  of  a  tongue 
depressor,  the  horizontal  portion   of  which  is  flattened  in  its  inner 

-Harold   Hays,   in  the    Neiv    York   Medical  Journal,  April  19,   1909,  and  the 
-Laryngoscope,   Jnlj,    1909. 


3i< 


THE   NOSE   AND   ACCESSORY    SINUSES 


two- thirds,  and  in  its  widest  part  measures  less  than  5/8  inch  (1.6  cm.) 
It  contains  a  central  tube  into  which  a  movable  telescope  fits  and  also 
two  wire  carriers.  At  the  distal  end  of  the  instrument  are  placed  two 
lamps,  one  on  each  side  of  the  telescope.  On  the  circumference  of  the 
eye-piece  of  the  telescope  is  a  small  metal  guide,  to  indicate  the  direc- 
tion in  which  the  lens  is  turned.  The  length  of  the  horizontal  portion 
including  the  telescope  is  about  8  inches  (20  cm.).  The  vertical 
portion  or  handle  of  the  instrument  contains  the  wires  which  carry 
the  current  to  the  lamps.  Near  its  upper  end  is  placed  a  switch  for 
turning  on  or  ofi"  the  current  (F-'g.  319). 

Asepsis. — The  instrument  must  be  thoroughly  sterilized  before 
use.     This  is  accomplished  by  means  of  formalin  vapor  or  by  immer- 


FiG.  320. — Showing   the   method   of   inserting   the   Hays'   pharyngoscope    (after 
Hays,  Am.  Jour.  Surg.,  Ma\%  1909). 


sion  in  a  I  to  20  carbolic  acid  solution  followed  by  rinsing  in  alcohol 
or  sterile  water.     It  will  not  stand  boiling. 

Anesthesia. — As  a  rule,  anesthesia  is  not  necessary.  Should, 
however,  gagging  be  induced  by  the  instrument,  the  posterior 
pharyngeal  wall  may  be  cocainized. 

Technic. — The  patient  is  instructed  to  open  his  mouth  widely 
and  breathe  quietly.  The  instrument  is  then  inserted  in  the  same 
manner  as  a  tongue  depressor,  until  its  distal  end  lies  about  1/16 
inch  (1.5  mm.)  from  the  pharyngeal  wall  (Fig.  320).  The  instru- 
ment is  kept  steadily  in  place  upon  the  tongue,  and  the  patient 
is  told  to  close  the  mouth  and  breathe  through  his  nose.     This 


PALPATION  BY   THE   PROBE 


319 


produces  relaxation  and  consequent  widening  of  the  pharynx  and 
nasopharynx.  The  hght  is  then  turned  on,  and  the  examiner 
inspects  the  structures  as  they  are  separately  brought  to  view  by 
rotation  of  the  telescope.  Thus  with  the  lens  pointing  upward,  as 
shown  by  the  knob  on  the  eye-piece,  the  pharyngeal  vault  is  brought 
to  view,  and,  by  tilting  the  distal  end  of  the  instrument  slightly 
upward,  the  posterior  nares  are  viewed. 

To  inspect  the  region  of  the  Eustachian  tubes  the  lens  is  rotated 
to  about  30  degrees  to  one  side,  when  the  orifices  of  the  tubes,  Rosen- 
miiller's  fossa,  etc.,  will  be  clearly  shown.  By  rotating  the  lens  so 
that  it  points  downward  the  epiglottis,  larynx,  and  base  of  the  tongue 
are  similarly  inspected. 


Fig.  321. — Showing  the  pharyngoscope  in  place  with  the  examiner  inspecting  the 

postnasal  space. 


PALPATION  BY  THE  PROBE 


The  use  of  the  probe  is  essential  to  a  complete  examination  of  the 
nose.  By  its  aid  the  consistency  and  character  of  structures  normally 
present,  as  well  as  the  presence  of  abnormal  growths,  adhesions, 
foreign  bodies,  and  the  patency  or  obstruction  of  the  openings  leading 
to  the  accessory  sinuses,  may  be  determined. 

Instruments. — The  instruments  comprise  those  necessary  for  a 
rhinoscopic  examination;  a  nasal  applicator;  a  nasal  probe;  and  a 
sinus  probe  (Fig.  322). 

The  nasal  probe  should  be  of  silver,  fairly  stiff,  but  at  the  same 


320 


THE   NOSE   AND   ACCESSORY    SINUSES 


time  capable  of  being  bent.  It  should  be  about  8  inches  (20  cm.) 
long,  and  set  into  its  handle  at  an  angle  of  135  degrees. 

The  instrument  employed  for  examination  of  the  sinuses  must  be 
of  pure  soft  silver  and  tine  in  size  so  that  it  may  be  readily  bent  to  any 
curve  or  be  adjusted  to  the  shape  of  the  region  through  which  it  has  to 
pass. 

Asepsis. — The  speculum,  applicator,  and  probes  are  sterilized  by 
boiling. 

Anesthesia. — The  nasal  mucous  membrane  is  very  sensitive  and 
manipulations  are  apt  to  produce  sneezing,  so  that  the  parts  should 
be  cocainized  before  the  probe  is  employed.  This  may  be  done  by 
applying  a  4  per  cent,  solution  on  a  small  pledget  of  cotton,  allowing 
sufficient  time  to  elapse  for  the  cocain  to  take  eflfect  before  proceeding 
with  the  examination. 


Fig.  322. — Instruments  for  palpating  the  interior  of  the  nose.      I,    Nasal  ap- 
plicator; 2,   nasal    probe;  3,    sinus    probe;  4,    Myles'    nasal    speculum;  5,    head 


Position  of  Patient. — The  positions  of  the  patient  and  operator  are 
the  same  as  for  a  rhinoscopic  examination  (see  page  312). 

Technic. — By  means  of  a  speculum  and  reflected  light  the  interior 
of  the  nasal  cavity  is  brought  into  view  and  is  then  systematically 
explored  by  the  probe.  Any  growths  are  touched  to  determine  their 
consistency,  and  masses  that  may  be  hidden  beneath  the  turbinates  and 
otherwise  escape  attention  may  be  rolled  into  view  by  means  of  the 
probe.  The  condition  of  the  mucous  membrane,  the  presence  and 
depth  of  ulcerations,  etc.,  are  ascertained.  All  recesses  should  be 
thoroughly  examined,  and  especially  the  walls  of  the  sinuses  should 
be  gently  palpated  for  the  presence  of  dead  bone. 

In  the  presence  of  symptoms  or  signs  pointing  to  involvement  of 
the  sinuses,  the  sinus  probe  should  be  employed  to  determine  their 


PALPATION  BY   THE   PROBE 


321 


condition  and  the  patency  of  their  ostia  as  a  preliminary  to  irrigation. 
On  account  of  the  anatomical  arrangement  of  the  parts,  probing  is 
practically  limited  to  the  sphenoidal  and  frontal  sinuses  unless  the 
middle  turbinate  is  first  removed.  Before  making  any  exploration  of 
these  cavities,  any  visible  pus  or  discharge  is  wiped  away  and  the 
nasal  cavity  cleansed  by  syringing. 


Fig.  323. — Showing  the  steps  in  the  passage  of  a  probe  into  the  frontal  sinus. 

To  enter  the  frontal  sinus,  the  distal  end  of  the  probe,  bent  to  an 
angel  of  135  degrees,  is  inserted  within  the  middle  meatus  at  the  junc- 
tion of  the  anterior  third  and  posterior  two-thirds  of  the  middle  tur- 
binate. Its  tip  is  made  to  hug  the  outer  wall  of  the  middle  turbinate, 
and  is  passed  upward  and  forward  through  the  hiatus  and  into  the 


Pig.  324. — Showing  the  steps  in  the  passage  of  a  probe  into  the  sphenoidal  sinus. 

infundibulum.  By  depressing  the  handle  of  the  instrument,  its  tip 
will  traverse  the  infundibulum  and  pass  through  the  ostium  frontale 
unless  some  obstruction  exists.  Gentleness  should  be  employed  in 
this  maneuver,  and  no  attempt  should  be  made  to  force  the  instru- 
ment if  any  obstruction  to  its  passage  exists. 


?s22 


THE   NOSE   AND   ACCESSORY    SINUSES 


To  enter  the  sphenoidal  sinus,  the  end  of  the  probe  is  bent  to  a 
slight  curve  and  is  passed  into  the  nose  with  its  convexity  upward. 
The  tip  of  the  instrument  is  made  to  traverse  the  roof  of  the  nasal 
fossa  until  it  meets  the  resistance  of  the  anterior  sphenoidal  wall. 
The  probe  is  then  moved  gently  about  in  various  directions  until  its 
point  enters  the  cavity  of  the  sinus,  which  is  then  carefully  explored. 

In  either  case,  when  the  probing  is  employed  as  a  preliminary  to 
irrigation,  and  the  particular  sinus  has  been  successfully  entered  by 
the  probe,  if  the  shape  of  the  irrigator  be  made  to  correspond  to  that 
of  the  probe  it  will  be  of  great  help  in  the  introduction  of  the  former. 

DIGITAL  PALPATION 

Palpation  of  the  posterior  nares  by  means  of  the  finger  is  employed 
to  confirm  the  diagnosis  made  by  posterior  rhinoscopy,  or  to  obtain 


Fig.  325. — Showing  the  method  of  palpating  the  postnasal  space  with  the  finger. 


information  as  to  the  condition  of  these  parts  when  the  latter  is  not 
possible.  Xo  instruments  are  needed,  except  in  the  case  of  unruly 
children,  when  a  mouth  gag  may  be  required.  While  digital  palpa- 
tion is  a  rather  unpleasant  procedure  for  the  patient,  if  performed 
rapidly  and  skilfully  many  of  the  disagreeable  features  may  be 
eliminated. 


TRANSILLUMINATION  323 

Preparations. — The  operator's  hands  should  always  be  well 
scrubbed  before  making  such  an  examination. 

Technic. — It  is  well  to  first  explain  to  the  patient  what  is  intended 
to  be  done.  The  patient  is  then  directed  to  open  the  mouth  widely. 
The  left  hand  of  the  operator  supports  the  patient's  head,  and  at  the 
same  time  with  the  thumb  or  index  finger  of  the  same  hand  he  forces 
the  cheek  in  between  the  open  jaws  to  prevent  the  examining  finger 
from  being  bitten  (Fig.  325).  The  index  finger  of  the  right  hand  is 
then  gently  but  quickly  introduced  into  the  mouth  and  is  hooked 
around  the  posterior  border  of  the  soft  palate  into  the  nasopharynx, 
and  the  parts  are  palpated.  In  this  way  the  presence  of  adenoids, 
hypertrophies  of  the  posterior  ends  of  the  turbinates,  or  other  growths 
are  readily  recognized. 

TRANSILLUMINATIOlSr 

Transillumination  is  a  valuable  aid  for  determining  the  conditiori 
of  the  frontal  or  maxillary  sinuses.  Its  use  in  connection  with  other 
sinuses  is  futile.  This  method  of  diagnosis  becomes  possible  from  the 
fact  that  the  air  spaces,  when  in  a  healthy  state,  transmit  light 
through  their  thin  walls,  which  power  is  diminished  when  pus  is 


Fig,  326. — Coakley's  transilluminator.  a,  Apparatus  assembled  for  trans- 
illumination of  the  antrum;  b,  glass  hood  for  use  in  transillumination  of  the  antrum; 
c,  hood  for  use  in  transillumination  of  the  frontal  sinus. 

present  or  the  mucous  membrane  lining  the  cavity  is  much  thickened. 
Transillumination  is  not  an  infallible  method,  by  any  means,  the 
chief  causes  of  error  being  imperfect  symmetry  of  the  two  sides,  due 
to  a  difference  in  the  size  of  the  two  sinuses  or  to  a  variation  in  the 
thickness  of  the  bony  walls.  Another  source  of  error  occurs  when 
involvement  of  both  sides  of  a  pair  of  sinuses  exists,  and  there  is  there- 
fore nothing  upon  which  to  base  a  comparison.  The  method  is  of 
greatest  service  in  the  diagnosis  of  empyema  of  the  antrum  and  of  the 
frontal  sinus.  In  the  latter  it  is  not  so  valuable  or  nearly  so  reliable 
an  aid  as  in  the  former,  for  the  size  of  the  two  frontal  sinuses  and  the 
thickness  in  the  individual  bones  are  apt  to  vary. 


324 


THE    NOSE   AND   ACCESSORY   SINUSES 


Apparatus. — There  are  many  lamps  adapted  to  the  purpose  of 
transillumination,  Coakley's  being  an  excellent  model.  This  con- 
sists of  a  handle  of  nonconducting  material  containing  a  lamp  and 
glass  hood  for  transillumination  of  the  maxillary  sinus,  and  a  second 


\ /■ 


^t) 


Fig.     327. — Transillumination  eflFect 
in  a  normal  right  frontal  sinus. 


Fig.  328. — Transillumination     effect 
in  a  diseased  left  frontal  sinus. 


hood  to  fit  over  the  lamp  in  place  of  the  glass  one.  for  use  about  the 
frontal  sinus  (Fig.  326).  The  lamps  are  of  about  four  or  five  candle- 
power,  the  electricity  being  supplied  by  a  small  battery  or  the  street 


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Fig.  329. — Transillumination  effect 
in  the  normal  case.  (After  Harmon 
Smith,  in  Keen's  Surgery.) 


Fig.  330. — Transillumination  effect 
in  sinusitis  of  the  right  antrum.  (After 
Harmon  Smith,  in  Keen's  Surgery.) 


current.     In  employing  the  latter,  a  current  controller,  by  which  the 
amount  of  current  may  be  regulated,  will  be  necessary. 

Technic. — i.  Transillumination     of    the     Frontal     Sinus. — The 
patient  is  seated  in  a  dark  room.     The  black  hood  is  drawn  over  the 


NASAL   DOUCHING 


325 


transilluminator  and  the  instrument  is  placed  beneath  the  orbital 
portion  of  the  brow  at  the  nasal  side.  The  light  is  turned  on  and  the 
sinus  is  clearly  illuminated,  the  operator  noting  the  effect.  The  oppo- 
site side  is  treated  in  the  same  manner,  and  the  two  are  compared  as 
to  the  intensity  with  which  the  light  is  transmitted. 

Through  a  large  sinus  in  a  normal  condition  the  light  is  transmitted 
with  greater  intensity  than  through  a  small  cavity,  or  through  one 
with  thickening  of  the  bony  walls  or  the  lining  membrane,  or  one 
complicated  by  the  presence  of  pus  or  a  tumor. 

2.  Transillumination  of  the  Antrum. — The  patient  is  seated  in  a 
darkened  room,  any  dental  plates  or  obturators  that  might  obstruct 
the  light  having  been  previously  removed.  The  electric  lamp, 
covered  with  the  glass  hood,  is  then  introduced  into  the  mouth,  and 
the  patient  is  instructed  to  close  his  lips  firmly.  Under  normal  con- 
ditions when  the  lamp  is  lighted,  the  cheeks,  up  to  the  infraorbital 
margins,  and  both  pupils  are  clearly  illuminated.  If  one  antrum  con- 
tains pus  or  a  solid  tumor,  the  malar  region  of  that  side  will  appear 
darker  and  an  absence  of  illumination  of  the  pupil  will  be  noted.  The 
transmission  of  light  will  also  be  interfered  with  in  the  presence  of 
thickened  walls  or  lining  mucous  membrane. 

SKIAGRAPHY 

The  X-ray  gives  important  information  in  regard  to  the  frontal, 
ethmoid,  and  maxillary  sinuses,  and,  when  possible,  it  should  be  regu- 
larly employed  as  one  of  the  aids  in  diagnosis.  To  be  of  any  value, 
however,  it  must  be  applied  by  a  competent  radiographer.  It  is 
especially  valuable  in  diseases  of  the  frontal  sinuses.  In  a  healthy 
condition,  the  outlines  of  the  sinuses  are  clear  and  distinct;  while  in 
diseased  conditions  the  outlines  are  not  so  clearly  indicated  and  the 
whole  area  of  the  sinus  appears  cloudy.  In  addition  the  X-ray  will 
show  the  size  and  shape  of  the  frontal  sinus  and  the  position  of  the 
septum,  all  of  which  are  important  points  in  making  a  decision  as  to 
method  of  operating,  should  it  be  necessary.  To  determine  the  size 
of  a  sinus  it  is  necessary  to  take  two  plates,  one  in  profile  and  the 
other  full  face. 

Therapeutic  Measures 

NASAL   DOUCHING 

Nasal  douching  is  employed  for  the  purpose  of  cleansing  the  nasal 
cavity  prior  to  operative  procedures  or  for  the  purpose  of  removing 


326 


THE   NOSE    AND   ACCESSORY    SINUSES 


secretions  or  crusts  preparatory  to  the  application  of  other  remedies. 
It  must  always  be  used  with  due  precautions,  for  there  is  considerable 
risk  where  fluid  is  forced  into  the  nose  in  bulk  that  some  of  it  will  enter 
the  Eustachian  tubes  and  cause  an  otitis  media.  For  this  reason 
only  small  quantities  of  solution  are  employed  at  a  time,  and  the  injec- 
tion should  be  made  without  any  force.  If  one  side  of  the  nose  is 
obstructed,  the  solution  should  enter  by  that  nostril  and  escape  from 
the  more  open  one.  As  a  further  precaution,  any  excess  of  fluid 
remaining  after  the  irrigation  should  be  allowed  to  flow  from  the  nose 
or  be  drawn  into  the  mouth  and  expectorated,  but  not  blown  from  the 
nose  for  fear  of  forcing  some  into  the  Eustachian  tubes.  The  patient 
should  furthermore  be  instructed  to  remain  indoors  for  at  least  half 
an  hour  after  each  irrigation  to  avoid  catching  cold.     For  the  patient's 


Fig.  331. — Nasal  douche  apparatus. 

own  use  nasal  spraying  is  a  safer  method  to  employ,  and,  if  it  becomes 
necessary  to  prescribe  a  nasal  douche,  the  surgeon  should  carefully 
instruct  the  patient  in  the  proper  method  of  its  use. 

Apparatus. — An  ordinary  douche  bag  with  a  capacity  of  about  a 
pint  (500  c.c),  fitted  with  a  nasal  nozzle,  forms  a  simple  and  effective 
douche.  There  are  a  number  of  douches  especially  made  for  the 
nose,  a  convenient  type  for  use  with  large  quantities  of  solution  being 
shown  in  Fig.  331.  It  consists  of  a  pint  bottle  to  the  bottom  of  which 
is  attached  a  rubber  tube  fitted  with  a  nasal  nozzle.  The  small  glass 
douche  (Fig.  332),  known  as  the  "Bermingham  douche,"  is  useful 
where  the  cleansing  is  to  be  carried  out  by  the  patient. 


NASAL   DOUCHING 


327 


Solutions. — For  ordinary  cleansing  purposes  the  solution  should 
be  alkaline  and  as  unirritating  as  possible. 

One  of  the  following  formulae  may  be  employed. 


I^.  Sodii  bicarbonatis, 

Sodii  biboratis, 

Acidi  carbolici, 

Glycerini, 

Aqu«,  q.   s.   ad. 

i^.  Sodii  bicarbonatis, 

Acidi  salicylici, 

Aquae,  q.   s.   ad. 

I^.  Sodii  bicarbonatis, 

Sodii  biboratis, 

Sodii  chloridi, 
Sig.  A  teaspoonful  to  a  pint  of  warm  water. 


aa.  dr.  i  (4  gm.) 
nrixv  (i  c.c.) 
oz.  i  (30  c.c.) 

Oi(5oo  c.c.)     M. 
dr.  i  (4  gm.) 
gr.  X  (0.65  gm.) 
Oi  (500  c.c.)     M. 


aa.  oz.  i  (30  c.c.)       M. 


Some  of  the  proprietary  preparations,  such  as  listerin,  borolyptol, 
glycothymolin,  alkalol,  etc.,  will  be  found  of  value  where  an  antiseptic 


Fig.  332. — The  Bermingham  nasal  douche. 

action  is  also  desired.  They  may  be  used  in  the  proportion  of  dr.  ss 
to  dr.  i  (2  to  4  c.c.)  to  the  ounce  (30  c.c.)  of  water.  When  there 
is  an  offensive  discharge,  the  following  may  be  employed. 


I^.  Potassii  permanganatis, 
Aquae, 


gr.  i-ii  (o .  06-0 . 1  gm.) 
ad.  oz.   i  (30  c.c.)      M. 


Temperature. — All  solutions  should  be  used  warm,  at  a  tempera- 
ture of  about  100°  F.  (38°  C). 

Quantity. — For  ordinary  cleansing  purposes  or  for  the  removal 
of  free  secretion  from  the  nose,  a  few  ounces  of  solution  are  sufi&cient. 
When  hard  crusts  are  abundant,  however,  it  sometimes  requires  a 
pint  (500  c.c.)  of  solution,  or  more,  to  loosen  them  and  effect  their 
removal. 

Rapidity  of  Flow. — The  solution  should  be  injected  with  only 
sufficient  force  to  permit  its  return  from  the  opposite  nostril  in  a  slow, 


328 


THE   NOSE    AND   ACCESSORY   SINUSES 


gentle  stream — never  under  high  pressure.  Accordingly,  the  reser- 
voir should  be  raised  only  2  or  3  inches  (5  to  7.5  cm.)  above  the  level 
of  the  nose. 

Technic. — The  patient  sits  with  his  head  bent  slightly  forward 
over  a  basin  or  sink,  with  a  towel  or  napkin  placed  about  his  neck  for 
protection  of  the  clothes.  The  douche  nozzle,  held  in  the  right  hand, 
is  then  inserted  into  one  nostril  with  sufficient  firmness  to  prevent  the 
solution  from  escaping,  while  with  the  left  hand  the  reservoir  is  raised 
a  few  inches  so  that  the  solution  enters  the  nose  in  a  weak  stream. 
The  patient  is  directed  to  breathe  through  his  mouth  and  to  avoid 
swallowing  during  the  lavage.     In  this  way,   when  the  patient's 


Fig.  333. — vShowing  the  method  of  using  the  nasal  douche. 


head  is  bent  forward,  the  fluid  does  not  escape  into  the  pharynx,  but 
passes  through  one  nostril  back  into  the  nasopharynx  and  out  through 
the  other  nostril  (Fig.  t,2>3)-  When  no  obstruction  exists  in  either 
side,  half  the  solution  may  be  injected  through  one  nostril  and  the 
remainder  in  the  reverse  direction  through  the  other. 

With  the  small  glass  douche  cup  the  technic  is  very  simple. 
The  patient  inserts  the  nozzle  of  the  partially  filled  instrument  into 
one  nostril,  holding  the  finger  over  the  side  opening.  He  then  throws 
his  head  well  back  and  removes  his  finger  from  the  opening,  which 


THE    NASAL    SYRINGE  329 

allows  the  solution  to  flow  through  the  nose  into  the  mouth,  whence  it 
is  expectorated.     Each  nostril  in  turn  may  be  thus  irrigated. 

THE  NASAL  SYRINGE 

The  nasal  syringe  is  employed  mainly  for  cleansing  the  nose. 
The  solution  may  be  injected  either  from  the  front,  returning  through 
the  opposite  nostril,  after  the  manner  of  the  nasal  douche,  or  the  nose 
may  be  washed  out  from  behind  forward.  By  the  latter  method  the 
postnasal  space  may  be  more  effectually  cleansed  of  sticky  secretions 
and  mucus  than  by  injecting  the  solution  from  the  front.  The  same 
precautions  should  be  observed  in  using  the  syringe  as  have  been 
mentioned  for  the  use  of  the  douche. 

Instruments. — A  syringe  with  a  capacity  of  i  to  2  ounces  (30  to 
60  c.c),  made  of  metal  or  hard  rubber,  will  be  required.     It  should 


Fig.  334. — Xasal  sj^ringe  with  anterior  and  posterior  nasal  tips. 

be  supplied  with  a  straight  nozzle  for  injection  through  the  anterior 
nares,  and  with  one  bent  up  almost  at  right  angles  for  cleansing  the 
postnasal  space  (Fig.  334). 

Solutions. — Any  of  the  cleansing  solutions  mentioned  on  page 
327  may  be  employed.     They  should  always  be  used  warm. 

Technic. — In  employing  the  nasal  syringe  much  the  same  technic 
is  followed  as  with  the  douche,  observing  due  care  against  injecting 
the  solution  with  too  much  force,  etc.  The  nozzle  of  the  syringe  is 
inserted  into  one  nostril  and  the  patient  is  directed  to  keep  his  head 
bent  well  forward  over  a  receptacle  and  to  breathe  through  the 
mouth.  The  solution  is  then  slowly  injected  and  returns  through  the 
opposite  nostril.  The  irrigation  should  be  so  regulated  that  the  fluid 
returns  as  quickly  as  it  enters,  thus  avoiding  any  undue  accumulation 
in  the  postnasal  space  and  lessening  the  dangers  of  infecting  the  Eu- 
stachian tubes. 


00' 


THE    NOSE    AND   ACCESSORY   SINUSES 


To  syringe  from  the  posterior  nares,  a  tongue  depressor  is  intro- 
duced into  the  mouth  to  keep  the  tongue  out  of  the  way,  while  the 
distal  end  of  the  postnasal  tip  is  introduced  behind  the  soft  palate. 
The  patient  is  then  directed  to  hold  his  head  well  forward,  the  fluid  is 
slowly  injected  and  escapes  from  the  anterior  nares,  flushing  out  the 


Fig.  335. — Showing  the  method  of  syringing  the  nose  from  behind, 

postnasal  space  and  nose  from  behind  forward  (Fig.  335).  On 
account  of  the  sensitive  condition  of  the  parts  in  some  cases  it  may  be 
necessary  to  cocainize  the  pharynx  and  soft  palate  before  the  syring- 
ing can  be  properly  performed. 

THE  NASAL  SPRAY 
Sprays  or  atomizers  are  utilized  either  for  cleansing  purposes  or 
for  the  application  of  remedies  to  the  nasal  mucous  membrane  when 
it  is  not  necessary  to  confine  the  solution  to  one  particular  spot. 


Fig.  336. — Whitall  Tatum  atomizer.   • 

Apparatus. — The  simplest  form  of  atomizer  usually  proves  most 
satisfactory,  and  is  less  liable  to  get  out  of  order.     The  Whitall  Tatum 


THE    NASAL    SPRAY 


33^ 


(Fig.  336),  the  Davidson,  or  the  De  Vilbiss  (Fig.  337)  are  all  good  at- 
•omizers.  The  latter  is  especially  serviceable,  and  the  spray  part, 
being  of  metal,  may  be  readily  sterilized.  The  instrument  should  be 
provided  with  a  straight  nasal  tip  as  well  as  with  a  postnasal  tip.  The 
air  current  may  be  supplied  by  a  rubber  compression  bulb  or  by  a 
compressed  air  apparatus  (Fig.  338).  The  latter  will  be  found  more 
convenient  for  ofi&ce  work. 

For  cleansing  purposes,  the  spray  should  be  rather  coarser  than 
that  employed  for  medication.     Oily  preparations  may  be  sprayed 


Fig.  337. — De  Vilbiss  atomizer. 

with  an  ordinary  atomizer  provided  with  an  oil  tip,  or  a  special  oil 
nebulizer  may  be  employed. 

Solutions. — Any  of  the  cleansing  solutions  mentioned  on  page  327 
may  be  employed  in  a  spray. 


Fig.  338. — Compressed-air  atomizing  apparatus. 
When  a  mild  antiseptic  action  is  desired,  the  solutions  given  on 


page  327  or  the  following  may  be  used: 

I^.  Acidi  carbolici 
Glycerini, 
Aquae  q, 


gr.  V  (0.3  gm.) 
dr.  i  (4  c.c.) 
s.  ad.  oz.  i  (30  c.c.)     M. 


332  THE   NOSE   AND    ACCESSORY   SINUSES 

I^.  Resorcini,  gr.  iii  (0.2  c.c.) 

Glycerini,  dr.  i  (4  c.c.) 

Aquae,  q.  s.  ad.  oz.  i  (30  c.c.)     M. 

Astringent  solutions,  for  purposes  of  lessening  secretions,  include 
such  drugs  as  zinc  sulphocarbolate,  zinc  sulphate,  copper  sulphate, 
alum,  tannic  acid,  silver  nitrate,  etc.,  used  in  the  strength  of  5  gr. 
(0.3  gm.)  to  the  ounce  (30  c.c.)  of  water. 

Oily  preparations,  with  albolene  or  benzoinol  as  a  base,  are  fre- 
quently used  after  the  application  of  aqueous  solutions  for  the  purpose 
of  protecting  the  parts,  the  oil  being  deposited  upon  the  mucous 
membrane  in  a  thin  coat.  Usually  eucalyptol,  camphor,  menthol,  or 
thymol  are  combined  with  the  oil  in  the  proportion  of  2  to  5  gr.  (o.i 
to  0.3  gm.)  or  more  to  the  ounce  (30  c.c.)  for  the  sedative  effect,  as 
in  the  following: 

I^.  Eucalyptol,  T([x  (0.6  c.c.) 

Menthol,  gr.  v  (0.3  gm.) 

Benzoinol,  oz.  i  (30  c.c.)     M. 

I^.  Thymol, 

Menthol,  aa  gr.  ii  (o.i  gm.) 

Albolene,  oz.  i  (30  c.c.)     M. 

I^.  Camphors. 

Menthol,  aa  gr.  v  (0.3  gm.) 

Albolene,  oz.  i  (30  c.c.)     M. 

When  a  stimulating  action  is  indicated,  the  proportion  of  the 
above  drugs  may  be  increased. 

Technic. — The  tip  of  the  nose  is  gently  raised  and  the  nozzle  of 
the  spray  is  inserted  into  the  vestibule.  To  avoid  injuring  the 
mucous  membrane  of  the  septum  or  turbinates,  care  should  be  taken 
to  keep  the  long  axis  of  the  spray  and  that  of  the  nose  in  the  same  line. 
By  alternately  compressing  and  relaxing  the  rubber  bulb,  the  solution 
is  forced  into  the  nose  in  a  spray.  The  direction  of  the  spray  should 
be  altered  from  time  to  time  by  raising  or  lowering  the  proximal  end 
of  the  atomizer. 

For  spraying  from  the  posterior  nares,  the  same  technic  is 
employed  as  with  the  postnasal  syringe  (see  page  330). 

THE  DIRECT  APPLICATION  OF  REMEDIES 

This  method  is  employed  for  the  application  of  strong  solutions  or 
sohd  caustics,  or  when  it  is  desired  to  confine  the  action  of  the  remedy 
to  any  particular  area. 


THE   DIRECT   APPLICATION    OP    REMEDIES 


333 


Fig.  339. — Fusing  chromic  acid  on  a  probe.     First  step,  heating  the  probe. 

(Gleason.) 


Fig.  340. 


Fig.  341. 


Fig.  342. 


Fig.  340. — Fusing  chromic  acid  on  a  probe.  Second  step,  dipping  the  hot 
probe  in  the  crystals.      (Gleason.) 

Fig.  341. — Fusing  chromic  acid  on  a  probe.  Third  step,  heating  the  crystals 
into  a  bead.     (Gleason.) 

Fig.  342. — Fusing  chromic  acid  on  probe.  Showing  the  finished  probe. 
(Gleason.) 


334  THE    NOSE   AND   ACCESSORY    SINUSES 

Instruments. — For  the  application  of  solutions,  a  nasal  applicator, 
the  tip  of  which  is  wound  with  a  thin  layer  of  cotton,  is  employed. 
Solid  caustics,  as  chromic  acid,  silver  nitrate,  etc.,  are  best  applied 
fused  upon  a  probe  or  applicator. 

Chromic  acid  may  be  prepared  for  application  as  follows:  The 
probe  tip  is  brought  to  a  red  heat  over  an  alcohol  flame  (Fig.  339) 
and  is  then  dipped  into  crystals  of  the  acid  (Fig.  340).  Upon  with- 
drawing the  probe  a  few  crystals  will  be  found  adhering  to  its  point. 
This  mass  is  then  heated  in  the  flame  until  the  crystals  begin  to  melt 
(Fig.  341),  and,  upon  cooling,  they  recrystallize  in  the  form  of  a  bead 
on  the  end  of  the  instrument  (Fig.  342).  If  it  is  desired  to  employ 
silver  nitrate  in  this  way,  a  few  of  the  crystals  should  be  melted  in  a 
crucible.  The  tip  of  a  probe  or  applicator  is  then  dipped  into  this 
liquid  mass  until  sufficient  of  the  caustic  adheres,  and,  as  soon  as  it 
solidifies,  it  is  ready  for  use.  In  applying  chromic  acid  a  second  cot- 
ton-wrapped applicator,  saturated  with  a  solution  of  bicarbonate  of 
soda — 30  gr.  (2  gm.)  to  the  ounce  (^o  c.c.) — should  be  at  hand  to 
neutralize  any  excess  of  acid. 

Anesthesia. — The  parts  should  be  cocainized  by  the  appHcation  of 
a  4  per  cent,  solution  of  cocain. 

Technic. — The  mucous  membrane  is  well  cleansed,  and,  when 
using  caustics,  the  area  to  be  treated  is  rendered  as  dry  as  possible  to 
prevent  the  caustic  spreading  over  too  large  a  surface.  The  appli- 
cation is  then  made  to  the  diseased  spot  under  guidance  of  the  nasal 
speculum,  being  careful  not  to  allow  the  applicator  to  touch  any  other 
points.  If  acid  is  employed,  any  excess  is  immediately  neutralized 
with  the  strong  solution  of  bicarbonate  of  soda  by  means  of  an  applica- 
tor previously  prepared  and  in  readiness. 

INSUFFLATIONS 

Various  powders  with  sedative  or  antiseptic  properties  are  applied 
to  the  nasal  mucous  membrane  by  means  of  a  special  powder  blower. 
Finely  powdered  starch,  stearate  of  zinc,  or  powdered  acacia  is  usu- 
ally employed  as  a  base,  in  the  proportion  of  two  parts  to  one  of  the 
active  principle.  Nosophen,  aristol.  europhen,  iodoform,  iodal,  etc., 
are  remedies  frequently  applied  in  this  manner.  Morphin  and  cocain 
in  small  doses  may  be  combined  with  these  powders  when  indicated. 

Instruments. — The  insufflator  shown  in  Fig.  343  or  that  shown  in 
Fig.  344  may  be  used.  The  former  is  made  on  the  same  principle 
as  a  hand  spray,  but  with  larger  tubes.  It,  however,  requires  the 
use  of  both  hands  in  its  manipulation.     The  latter  instrument  con- 


INSUFFLATIONS 


335 


sists  of  a  rubber  compression  bulb  to  which  is  fitted  a  vulcanized 
rubber  tube.  Into  this  latter  fits  the  nasal  tip,  the  proximal  end  of 
which  is  made  in  the  form  of  a  scoop  for  taking  up  the  powder.  When 
the  instrument  is  filled,  a  sudden  compression  of  the  bulb  forces  air 
through  the  apparatus,  blowing  the  powder  out  in  front  of  it.     This 


Fig.  343. — Powder  blower. 

instrument  may  be  manipulated  with  one  hand,  and  the  quantity  of 
powder  used  can  be  accurately  measured.  Insuffiators  are  supplied 
with  straight  tips  for  the  anterior  nares,  and  with  curved  tips  for 
making  applications  to  the  posterior  nares. 


Fig.  344. — Scoop  powder  blower. 

For  the  patient's  use,  an  insufflator  such  as  Sajous'  (Fig.  345)  will 
be  found  convenient.  It  consists  of  a  small  glass  receptacle  with  an 
opening  for  pouring  in  the  powder,  to  one  end  of  which  a  rubber 
mouthpiece  is  attached,  the  other  end  being  rounded  off  to  fit  into  the 
nostril. 


Fig.  345. — Sajous'  powder  blower. 

Technic. — With  a  suitable  powder  blower,  the  application  of 
powders  is  very  simple.  The  instrument  being  properly  filled,  the 
tip  is  inserted  into  the  nostril  or  up  behind  the  soft  palate,  according 


336  THE   NOSE   AND   ACCESSORY   SINUSES 

to  whether  the  anterior  or  the  posterior  portions  of  the  nose  are  to 
be  medicated,  and,  with  two  or  three  rapid  compressions  of  the  bulb, 
the  powder  is  forced  out  of  the  instrument  and  is  deposited  upon  the 
mucous  membrane. 

When  the  insufflation  is  performed  by  the  mouth,  as  with  the 
Sajous  insufflator,  the  tip  is  inserted  into  the  nostril,  the  instrument 
being  held  with  one  finger  over  the  opening  in  the  bottom  of  the 
receptacle  to  make  it  air-tight.  The  mouthpiece  is  held  between  the 
lips  and,  by  one  or  more  gentle  puffs,  the  powder  is  blown  out  upon  the 
parts  to  be  medicated. 

LAVAGE  OF  THE  ACCESSORY  SINUSES 

This  procedure  is  employed  as  a  means  of  diagnosis,  for  the  purpose 
of  removing  purulent  secretions,  and  for  cleansing  the  mucous 
lining  in  the  treatment  of  suppuration  involving  the  accessory  sinuses. 
It  is  performed  by  means  of  a  suitable  cannula  introduced  into  the 
sinus  through  the  natural  or  an  artificial  opening.  Treatment  by 
irrigation  is  most  successful  in  the  early  cases  of  empyema;  in  those 
complicated  by  granulation  tissue  or  dead  bone,  it  is  not  so  satisfac- 
tory. It  should,  however,  be  given  a  trial  in  any  case  before  the  more 
radical  surgical  measures  are  considered. 

Solutions  Used. — Normal  saline  solution  (salt  oi  (4  gm.)  to  the 
pint  (500  c.c.)  of  boiled  water),  a  saturated  solution  of  boric  acid, 
or  any  of  the  cleansing  solutions  mentioned  on  page  327  may  be  used. 

Temperature. — All  solutions  employed  in  irrigating  should  be 
warm — at  about  100°  F.  (38°  C). 

Lavage  of  the  Maxillary  Sinus. — It  is  rarely  possible  to  insert  a 
probe  or  cannula  into  the  maxillary  sinus  through  its  normal  opening, 
on  account  oi  its  hidden  position  and  the  fact  that  the  opening  is 
directed  somewhat  downward  and  forward  from  the  infundibulum. 
If  an  accessory  opening  be  present,  however,  it  may  be  possible  to 
irrigate  through  it,  but  in  most  cases  an  artificial  opening  will  have  to 
be  made  through  the  inferior  turbinate,  or  through  the  alveolus  after 
removal  of  the  second  bicuspid,  or  the  first  or  second  molar  tooth. 
The  former  approach  should  be  chosen  when  the  teeth  are  sound  and 
the  origin  of  infection  is  apparently  from  the  nose.  When  a  decayed 
tooth  is  the  source  of  trouble  and  the  tooth  is  beyond  saving,  puncture 
through  the  alveolus  is  justifiable. 

Instruments. — For  irrigating  through  the  inferior  meatus,  an 
antrum  trocar  and  cannula  and  small  syringe  will  be  required.  For 
opening  through  the  alveolus,  there  should  be  provided  suitable  tooth- 


LAVAGE    or    THE    ACCESSORY    SINUSES 


337 


Fig.  346. — Instruments  for  lavage  of  the  maxillary  sinus  through  a  puncture  in 
the  inferior  meatus.  I,  Head  mirror;  2,  syringe;  3,  applicator;  4,  Myles'  nasal 
speculum;  5,  tubing  to  connect  the  syringe  and  cannula;  6,  Myles'  trocar  and 
cannula. 


Fig.  347. — Instruments  for  lavage  of  the  antrum  through  the  alveolus,  i. 
Syringe;  2,  cannula;  3,  tubing  to  connect  the  syringe  to  the  cannula;  4,  alveolar 
drill;  5,  drainage-tube;  6,  tooth-extracting  forceps. 


338 


THE   NOSE   AND   ACCESSORY   SINUSES 


pulling  forceps,  an  alveolar  drill,  a  syringe,  and  a  silver  or  aluminum 
tube  of  the  same  caliber  as  the  drill,  1/2  to  3/4  inch  (i  to  2  cm.)  long 
and  provided  with  a  flange  to  prevent  its  slipping  into  the  antrum. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  and  the 
patient's  nose  is  cleansed  by  gentle  syringing. 

Anesthesia. — For  puncture  of  the  antrum  through  the  inferior 
meatus,  local  anesthesia  by  the  application  of  a  4  per  cent,  solution  of 
cocain  on  a  pledget  of  cotton  twenty  minutes  before  will  be  sufficient. 

Nitrous  oxid  anesthesia  should  be  employed  for  the  extraction 
of  a  tooth  and  drilling  through  the  alveolus. 

Technic. —  i.  Through  the  Inferior  Meatus. — Having  obtained  a 
good  view  of  the  interior  of  the  nose  by  the  aid  of  a  speculum  and 
reflected  light,  a  point  is  selected  just  beneath  the  inferior  turbinate 


Fig.  348. — Showing  the  method  of  puncturing  the  antrum  through  the  inferior 

meatus. 


and  about  1/2  inch  (i  cm.)  behind  its  anterior  extremity,  and  the 
trocar  is  introduced,  pushing  it  in  an  outward,  backward,  and  slightly 
upward  direction,  through  the  thin  bony  wall  into  the  antrum  (Fig. 
348).  The  relation  of  the  sinus  to  the  orbit  should  be  borne  in 
mind  when  making  this  puncture  and  care  taken  not  to  enter  the  lat- 
ter; this  may  happen  if  the  puncture  be  made  through  the  middle 
meatus  (Fig.  349).  As  soon  as  the  antrum  has  been  entered,  the 
trocar  is  withdrawn.  The  syringe  is  then  attached  to  the  cannula  by 
a  piece  of  rubber  tubing,  and  the  cavity  thoroughly  irrigated.  Any 
secretion  is  thus  forced  out  through  the  normal  opening  of  the  sinus 
and  appears  in  the  middle  meatus.  During  the  irrigation,  the  head 
should  be  held  downward  over  a  receptacle,  so  that  the  solution  will 
readily  escape  from  the  nose. 

The  sinus  should  be  irrigated  daily  until  the  discharge  ceases, 
employing  stronger  or  more  stimulating  solutions  if  they  seem  indi- 
cated.    Usually  there  is  no  great  difficulty  in  reinserting  the  cannula 


LAVAGE    or   THE   ACCESSORY    SINUSES 


339 


through  the  opening  each  day,  if  it  is  provided  with  a  blunt  obturator. 
The  parts  should  be  cocainized,  however,  before  each  irrigation. 

2.  Through  the  Alveolus. — The  puncture  is  made  through  the 


Mddle/li&TlSs, 

/Intfuirt  of 
Highuiore 

Jnfer/'crAfea/us 


Fig.  349. — Transverse  section  through  the  nose,  showing  cannula,  a.  Entering 
antrum  through  inferior  meatus;  and  h,  cannula  entering  the  orbit  through  the 
middle  meatus.      (After  Coffin.) 


socket  of  the  second  bicuspid  or  the  inner  root  socket  of  the  first  or 
second  molar  tooth  (Fig.  350).  The  affected  tooth  is  first  removed, 
and  the  drill  inserted  by  a  boring  motion,  as  follows:  For  the  first 
molar,  in  an  upward  and  slightly  inward  direction;  for  the  second 


Fig.  350. — Showing   drills   entering   the   antrum   through   the   alveolus.      (After 
Schultze  and  Stewart.) 

molar,  in  an  upward,  slightly  inward  and  forward  direction;  and  for 
the  second  bicuspid,  upward,  slightly  inward,  and  backward.  Unless 
the  approximate  position  of  the  antrum  is  kept  in  mind  and  the  drill 
inserted  accordingly,  the  cavity  may  be  missed.     As  soon  as  the  an- 


340 


THE    NOSE    AND    ACCESSORY    SINUSES 


trum  has  been  entered  the  cavit}-  is  irrigated  by  means  of  a  syringe,  the 
solution  escaping  into  the  nose  through  the  natural  opening.  To  aid 
its  escape,  the  patient's  head  should  be  inclined  forward.  Finally,  a 
metal  drainage-tube  of  the  proper  size  is  inserted,  through  which 
subsequent  irrigations  may  be  made. 

The  irrigations  may  be  performed  once  or  twice  a  day,  and  later 
they  may  be  carried  out  by  the  patient  himself.  When  the  discharge 
ceases,  the  irrigations  are  discontinued  for  a  day  or  two,  and,  if  there 
is  no  recurrence  of  the  trouble,  the  tube  is  then  removed  and  the 
opening  allowed  to  close. 

Lavage  of  the  Frontal  Sinus. — The  frontal  sinus  may  be  irri- 
gated by  means  of  a  small  cannula  introduced  through  the  fronto- 


FiG.  351. — Instruments  for  lavage  of  the  frontal  sinus.  i.Myles'  nasal  speculum; 
2,  head  mirror;  3,  syringe;4,  tubing  to  connect  the  syringe  to  cannula ;  5,  sinus  probe; 
6,  nasal  applicator;  7,  sinus  cannula. 


nasal  duct.  In  some  cases,  where  the  opening  is  occluded  by  the 
middle  turbinate  or  an  enlarged  bulla  ethmoidahs,  the  middle  turbi- 
nate will  have  to  be  removed  before  the  attempt  is  successful. 
Another  difficulty  presents  itself  in  the  close  proximity  of  the  anterior 
ethmoidal  cells,  and  the  cannula  may  enter  this  group  instead  of  the 
frontal  sinus. 

Instruments. — A  head  mirror,  a  speculum,  a  nasal  applicator,  a 
sinus  probe,  a  pure  soft-silver  sinus  cannula  that  may  be  easily  bent  to 


LAVAGE    OF    THE    ACCESSORY    SINUSES 


341 


accommodate  itself  to  any  curve — such  as  Hartmann's — and  a  syr- 
inge that  can  be  attached  by  means  of  rubber  tubing  will  be  required 
(Fig.  351). 


Fig.  352. — Showing  the  steps  of  passing  a  cannula  into  the  frontal  sinus. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  and  the 
patient's  nose  is  cleansed  by  gentle  syringing. 

Anesthesia. — A  4  per  cent,  solution  of  cocain  should  be  applied 
to  the  middle  meatus  for  twenty  minutes  before  the  operation. 


^  A.  <>  6 

Fig-  353- — Instruments  for  lavage  of  the  sphenoidal  sinus,  i,  Myles'  nasal 
speculum;  2,  head  mirror;  3,  syringe;  4,  tubing  to  connect  the  syringe  to  cannula; 
5,  sinus  probe;  6,  nasal  applicator;  7,  sinus  cannula. 

Technic. — The  cannula,  bent  at  its  distal  end  to  an  angle  of  about 
135  degrees,  is  introduced  into  the  middle  meatus  at  the  junction  of 
the  anterior  third  with  the  posterior  two-thirds.     The  tip  of  the 


342 


THE   NOSE    AXD   ACCESSORY   SINUSES 


cannula  is  passed  into  the  hiatus  and  then  forward  and  upward  into 
the  infundibulum.  and  thence  still  upward  and  slightly  forward  into 
the  sinus,  through  the  fronto-nasal  duct  (Fig.  352).  The  syringe  is 
then  attached  to  the  cannula  and  the  sinus  is  gently  irrigated  with  one 
of  the  warm  cleansing  solutions  previously  mentioned. 

Lavage  of  the  Sphenoidal  Sinus. — Instruments. — A  head  mirror, 
a  nasal  speculum,  a  nasal  applicator,  a  sinus  probe,  a  sphenoidal 
curved  cannula,  and  a  syringe  with  rubber-tubing  attachment  will 
be  required  (Fig.  353). 

Asepsis. — The  instruments  are  boiled,  and  the  patient's  nose  is 
cleansed  by  gentle  syringing. 

Anesthesia. — The  region  is  anesthetized  with  a  4  per  cent,  solu- 
tion of  cocain. 

Technic. — The  cannula  is  passed  into  the  nasal  cavity  with  the 
convexity  upward.     The  point  of  the  instrument  is  inserted  between 


Fig.  354. — Showing  the  steps  of  passing  a  cannula  into  the  sphenoidal  sinus. 


the  middle  turbinate  and  the  septum,  and  should  follow  the  roof  of  the 
nose  until  it  meets  the  resistance  of  the  anterior  wall  of  the  sphenoidal 
sinus.  By  gently  moving  the  instrument  up  and  down  and  from  side 
to  side,  its  tip  will  eventually  be  made  to  enter  the  sphenoidal  opening 
(Fig.  354).  The  depth  of  the  sinus  is  only  about  3/8  inch  (1.5  cm.), 
and  care  should  be  taken  not  to  force  the  instrument  through  its  thin 
walls.  The  syringe  is  attached  to  the  cannula  by  rubber  tubing,  and 
the  cavity  thoroughly  but  gently  irrigated.  During  this  procedure 
the  patient's  head  should  be  bent  forward  and  the  mouth  opened  to 
prevent  the  backward  flow  of  the  returning  solution. 


PASSIVE   HYPEREMIA    IN    DISEASES    OF    THE    NOSE  343 

PASSIVE   HYPEREMIA  IN   DISEASES   OF   THE   NOSE    AND 
ACCESSORY  SINUSES 

The  beneficial  effects  of  passive  hyperemia  in  the  treatment  of 
inflammations  have  aheady  been  discussed  in  Chapter  IX,  to  which 
section  the  reader  is  referred  for  a  full  consideration  of  the  subject 
and  the  technic  of  its  application.  According  to  Ballenger/  the  indi- 
cations for  passive  hyperemia  in  rhinology  are:  (i)  in  the  first  five 
days  of  acute  rhinitis;  (2)  in  the  first  five  days  of  acute  sinusitis;  (3) 
in  the  first  five  days  of  acute  inflammation  of  the  pharyngeal  tonsils; 
(4)  in  acute  tubal  catarrh;  (5)  in  chronic  purulent  inflammation  of 
the  sinuses. 

The  hyperemia  may  be  effected  by  means  of  a  neck-band  (as 
described  on  page  210)  or  by  a  special  form  of  suction  apparatus. 
The  latter  is  more  efiicacious  in  the  presence  of  a  purulent  discharge, 
the  vacuum  serving  to  remove  secretions  as  well  as  to  induce  a  benefi- 
cial hyperemia;  but  it  must  be  used  with  great  care  not  to  induce  a 
harmful  degree  of  hyperemia.  The  apparatus  shown  in  Fig.  196  or 
one  provided  with  glass  tips  which  fit  into  the  nostrils  may  be  used. 
With  the  apparatus  applied  to  the  nose,  the  air  is  slowly  rarefied 
while  the  patient  swallows.  This  causes  the  soft  palate  to  rise  up  in 
apposition  with  the  posterior  wall  of  the  pharynx  and  to  close  the 
naso-pharynx  and  nose  from  the  pharynx,  and  a  hyperemia  of  the 
mucous  membrane  of  naso-pharynx,  nose,  accessory  sinuses,  and 
Eustachian  tubes  is  thus  induced. 

TAMPONING  THE  NOSE   FOR  THE  CONTROL  OF 
HEMORRHAGE 

Nasal  hemorrhage  may  be  the  result  of  trauma,  ulcerations, 
new  growths,  cardiac  disease,  certain  constitutional  diseases  and  infec- 
tions, diseases  of  the  blood,  etc.  Usually  the  bleeding  ceases  spontane- 
ously or  under  simple  treatment  which  aims  at  lessening  the  conges- 
tion of  the  nasal  mucous  membrane  and  favoring  the  formation  of  a 
clot,  such  as  the  appKcation  of  cold  over  the  nose  and  at  the  base 
of  the  neck,  removing  tight  collars,  etc.,  from  the  neck,. or  having 
the  patient  remain  quietly  in  an  upright  position  with  the  head 
erect,  at  the  same  time  forbidding  any  attempts  at  blowing  the  nose. 

If  these  simple  measures  are  insuf&cient,  a  speculum  should  be 
introduced  and  the  interior  of  the  nose  inspected  for  the  source  of 
the  hemorrhage.     If  the  bleeding  point  is  within  reach,  it  should 

1  Ballenger:  "Diseases  of  the  Nose,  Throat,  and  Ear." 


344 


THE   NOSE    AND   ACCESSORY    SINUSES 


be  cauterized  by  touching  with  the  electro-cautery  or  with  silver 
nitrate;  or  else  some  styptic  solution,  as  peroxid  of  hydrogen,  a 
watery  solution  of  tannic  acid,  or  a  i  to  looo  solution  of  adrenalin 
chlorid  should  be  appHed  to  the  part  upon  a  pledget  of  cotton.  It 
may  be  impossible  to  locate  the  bleeding  point,  or  the  hemorrhage 
may  continue  in  spite  of  such  treatment,  so  that  in  the  presence  of 


Fig.  355. — Instruments  for  tamponing  the  anterior  nares.    i,  Nasal  applicator; 
2,  head  mirror;  3,  narrow  strip  of  gauze;  4,  Myles'  nasal  speculum. 

a  profuse  hemorrhage  it  becomes  necessary  to  pack  the  nose.  In 
the  majority  of  cases  tamponade  through  the  anterior  nares  will 
be  sufficient;  in  others,  the  bleeding  may  occur  posteriorly  and  the 
posterior  nares  as  well  will  have  to  be  packed. 

Instruments,  etc. — To  pack  the  nose  from  the  front,  a  head  mir- 


FlG.  356. — Catheter  for  drawing  plug  into  the  posterior  nares. 

ror,  a  nasal  speculum,  a  nasal  applicator,  and  a  single  narrow  strip  of 
gauze  should  be  provided  (Fig.  355). 

For  packing  the  posterior  nares  a  tampon  about  i  inch  (2 . 5  cm.) 
long  and  1/2  inch  (i  cm.)  thick,  should  be  prepared  by  rolling  a 
strip  of  gauze  to  the  required  size,  to  the  center  of  which  a  heavy 
piece  of  silk  thread  is  tied,  the  two  ends,  which  should  each  be  about 
28  inches  (45  cm.)  long,  being  left  free.     For  the  purpose  of  adjusting 


TAMPONING  THE  NOSE  EOR  CONTROL  OF  HEMORRHAGE 


345 


the  tampon  in  place,  a  rubber  urethral  catheter  of  a  size  that  will 
readily  pass  through  the  nose  into  the  mouth  (Fig.  356),  or  an  instru- 
ment especially  made  for  this  purpose,  known  as  Bellocq's  sound 
(Fig.  357),  will  be  necessary.  This  latter  consists  of  a  curved 
metal  cannula  containing  a  concealed  steel  spring,  which  is  protruded 


Fig.  357. — Bellocq's  cannula. 

into  the  pharynx  and  mouth  when  the  cannula  is  in  place  in  the  nose, 
and  to  the  end  of  which  the  tampon  is  then  attached. 

Asepsis. — The  instruments  are  boiled,  and  the  gauze  used  for  the 
tampon  should  be  sterile. 


Fig.  358. — Showing  the  method  of  tamponing  the  anterior  nares. 

Technic  {Anterior  Nares). — In  tamponing  the  anterior  nares  a 
speculum  is  inserted  in  the  nose  and  a  good  view  of  the  interior 
obtained.  A  narrow  strip  of  gauze,  saturated  with  peroxid  of  hydro- 
gen, is  then  gently  carried  well  back  into  the  nose  by  means  of  an 
applicator,  and  by  forcing  in  more  gauze  the  whole  nose  is  tamponed 


346 


THE   NOSE    AND   ACCESSORY   SINUSES 


and  the  hemorrhage  controlled  (Fig.  358).  This  packing  should 
always  be  removed  within  forty-eight  hours.  Only  a  single  strip  of 
gauze  should  be  used,  as  it  will  be  less  difficult  to  remove  and  there  is 


Fig.  359. — Showing  the  method  of  drawing  a  plug  into  the  posterior  nares  by  the 

aid  of  Bellocq's  cannula. 


Fig.  360. — The  posterior  nasal  plug  in  place. 

no  danger  of  leaving  any  behind  in  the  nose.     As  a  further  aid  in 
removal,  the  end  of  the  gauze  should  be  left  within  easy  reach. 

(2)   {Posterior  Nares). — The  tampon,  as  already  described,  should 


TAMPONING  THE  NOSE  EOR  CONTROL  OF  HEMORRHAGE    347 

be  well  lubricated  with  sterile  vaselin  and  placed  near  at  hand.  The 
Bellocq  cannula  is  passed  along  the  floor  of  the  nose  on  the  bleeding 
side  until  its  tip  appears  back  of  the  soft  palate.  The  steel  spring  is 
pushed  home  and  is  protruded  into  the  mouth.  The  tampon  is  then 
tied  to  the  end  of  the  carrier  by  one  of  the  strings  (Fig.  359),  the 
spring  returned  within  the  cannula,  and  the  latter  removed  from  the 
nose  and  with  it  the  end  of  the  tampon  spring.  By  pulling  upon  the 
string,  assisted  by  a  finger  placed  in  the  naso-pharynx,  the  tampon  is 
drawn  tightly  into  the  posterior  nares  (Fig.  360).  In  addition,  it  is 
well  to  pack  the  anterior  nares  with  gauze  or  a  plug  of  cotton,  over 
which  is  tied  the  string  protruding  from  the  nose.  The  other  end  of 
the  string,  which  is  left  in  place  for  the  purpose  of  removing  the  pack, 
is  brought  out  through  the  mouth  and  loosely  fastened  to  the  ear. 
When  an  ordinary  catheter  is  employed  in  place  of  a  special  sound, 
precisely  the  same  technic  is  followed. 

The  packing  should  be  removed  in  twenty-four  hours,  since,  if 
left  in  longer,  it  is  apt  to  set  up  an  irritation  and  may  lead  to  infection 
of  the  Eustachian  tube.  To  remove  the  pack,  the  string  tied  to  the 
anterior  tampon  is  first  cut  free.  The  naso-pharynx  should  be 
cleaned  of  blood-clots,  and  the  whole  region  sprayed  with  adrenalin 
chlorid  to  cause  the  tissues  to  shrink  as  much  as  possible.  The  poste- 
rior plug  is  then  removed  by  gentle  traction  upon  the  string. 


CHAPTER  XIV 
THE  EAR 

Anatomic  Considerations 

The  ear  is  divided  into  three  portions:  the  external  ear,  the  middle 
ear,  and  the  internal  ear.  For  the  purposes  of  this  work,  a  consid- 
eration of  the  anatomy  of  the  external  ear  and  the  middle  ear  will 
suffice. 

The  external  ear  comprises  the  auricle  or  pinna  and  the  external 
auditory  canal. 

The  auricle  is  the  irregular  shaped  mass  composed  of  fibrocartilage, 
covered  by  perichondrium,  connective  tissue,  and  skin,  which  pro- 
jects from  the  side  of  the  head.  It  has  the  function  of  collecting 
sounds  and  reflecting  them  to  the  external  auditory  meatus.     The 


Fig.  361. — The  left  auricle,      i,  Concha;  2,  antihelix;  3,  fossa  of  antihelix;  4,  helix; 
5,  fossa  of  the  helix;  6,  tragus;  7,  antitragus;  8,  lobule. 

central  depressed  portion,  resembHng  a  shell  in  form,  is  called  the  con- 
cha. It  is  bounded  by  a  rim,  the  antihelix,  which  runs  at  first  back- 
ward and  then  upward  and  forward,  finally  dividing  into  two  arms. 
The  space  between  these  two  arms  is  known  as  the  fossa  of  the  anti- 
helix. From  the  front  portion  of  the  concha  extends  a  ridge,  known 
as  the  helix,  at  first  in  a  forward  and  upward  direction  and  then 
around  the  circumference  of  the  auricle  toward  the  lowest  portion. 
The  space  between  the  antihelix  and  the  helix  is  designated  the  fossa 
of  the  helix.     The  small  backward  projection  lying  in  front  of  the  con- 

348 


ANATOMIC    CONSIDERATIONS 


349 


cha  is  called  the  tragus,  and  the  small  tubercle  at  the  lowest  portion 
of  the  antihelix,  the  antitragus.  The  lobule  of  the  ear  is  the  lowest 
soft  pendulous  portion  of  the  auricle. 

The  external  auditory  canal  extends  from  the  concha  to  the  drum 
membrane.  It  serves  the  purpose  of  conveying  sounds  collected  by 
the  auricle  to  the  drum  membrane.  The  canal  measures  about 
I  1/2  inches  (4  cm.)  in  length,  the  floor  being  slightly  longer  than  the 
roof  on  account  of  the  oblique  position  of  the  drum  membrane.  Its 
outer  third  is  composed  of  cartilage,  a  continuation  of  that  forming 
the  auricle,  while  the  inner  two-thirds  has  a  bony  framework.  The 
interior  is  lined  with  thin  skin,  which  contains  hair  follicles  and 
cerumenous  glands,  the  latter  being  most  abundant  at  the  junction 


/top/' ct/"  7j//npanum. 


Cerumenous 
Glands 


EusituAiianTulc 

laid  open 


Fig.  362. — Front  view  of  the  organ  of  hearing.      (Randall.) 


of  the  cartilaginous  and  bony  portions.  The  widest  portion  of  the 
canal  is  near  the  external  orifice,  the  narrowest  portion  near  the 
center,  and,  beyond  this,  as  it  nears  the  drum  membrane,  the  canal 
expands  again.  The  direction  of  the  canal  traced  from  without 
inward  is  at  first  upward  and  forward,  then  backward,  and  finally 
forward  and  downward.  By  traction,  however,  in  an  upward,  back- 
ward, and  outward  direction  upon  the  auricle  the  canal  may  be 
straightened  out  and  its  interior  viewed. 

The  middle  ear,  or  tympanum,  is  an  irregularly  shaped  cavity 
situated  in  the  petrous  portion  of  the  temporal  bone,  between  the 
external  and  the  internal  ear.  The  interior  of  the  cavity  is  lined  with 
a  delicate  mucous  membrane.  Within  it  lie  the  chain  of  ossicles,  the 
tympanic  muscles,  and  the  chorda  tympani  nerve. 


35° 


THE    EAR 


The  tympanic  cavity  is  bounded  above  by  the  roof,  consisting  of  a 
thin  plate  of  bone,  the  tegmen  tympani  et  antri,  which  separates  it 
from  the  dura;  below  by  the  floor  which  corresponds  to  the  jugular 
fossa;  by  an  outer  wall  composed  of  the  drum  membrane  and  the 
ring  of  bone  into  which  it  is  inserted;  by  an  inner  wall  which  is  con- 
tiguous to  the  labyrinth,  and  presents  an  oval  window  closed  by  the 
stapes  and  a  round  window  closed  by  membrane;  by  an  anterior  wall 
which  separates  the  tympanic  cavity  from  the  carotid  canal,  and  in 
the  upper  part  of  which  is  the  tympanic  orifice  of  the  Eustachian  tube 
and  above  this  the  canal  for  the  tensor  tympani  muscle;  and  by  a 
posterior  wall^  in  the  upper  part  of  which  lies  the  narrow  opening 
leading  into  the  mastoid  antrum,  the  aditus  ad  antrum.     The  cavity 


Aditus 


Stapes, 


Incus 


Jilalleus 


Eustachian 
tube 


Fig.  363. — Anatomy  of  the  ossicles.      (Pyle's  "Personal  Hygiene.") 


is  practically  divided  by  the  chain  of  ossicles  into  two  portions,  an 
upper  epitympanic  space  or  attic,  and  a  lower  cavity  or  atrium. 

The  ossicles  are  three  small  bones,  the  malleus  or  hammer,  the 
incus  or  anvil,  and  the  stapes  or  stirrup,  joined  together  by  movable 
articulations,  and  forming  an  osseous  chain  between  the  drum  mem- 
brane and  the  labyrinth.  They  are  held  in  place  by  the  attachment 
of  the  malleus  to  the  membrana  tympani  and  of  the  stapes  to  the 
oval  window,  and  in  addition  by  various  ligaments  extending  between 
them  and  the  bony  walls.  Their  function  is  to  convey  sound  waves 
from  the  drum  to  the  labyrinth. 

The  malleus  consists  of  an  oval  head  which  extends  upward  and 
articulates  with  the  incus,  a  neck,  a  manubrium  or  handle  which 


ANATOMIC    CONSIDERATIONS  35 1 

extends  downward  and  is  embedded  in  the  membrana  tympani,  a 
short  process,  which  extends  outward  from  the  neck  to  the  membrana 
tympani  and  pushes  the  latter  outward  before  it,  and  a  long  process 
which  passes  anteriorly  into  the  Glaserian  fissure. 

The  incus  is  the  middle  ossicle.  It  consists  of  a  body  which  artic- 
ulates with  the  malleus,  a  short  horizontal  process  which  extends  to 
the  posterior  wall  where  it  is  attached  by  ligaments,  and  a  long  process 
which  extends  downward  and  outward  and  then  near  its  tip  sharply 
inward  to  articulate  by  its  orbicular  process  with  the  head  of  the 
stapes. 

The  stapes  consists  of  a  broad  base  or  foot-piece  which  fits  into  the 
oval  window,  to  the  membrane  of  which  it  is  attached,  two  crura  or 
legs,  and  a  head  which  articulates  with  the  orbicular  process  of  the 
incus. 

The  membrana  tympani,  or  ear-drum,  is  a  thin  elastic  membrane 


Fig.  364. — Outer  surface  of  the  right  membrana  tympani.  (Gleason.)  a, 
Membrana  flaccida;  h,  posterior  fold;  c,  short  process;  d,  incudostapedial  articula- 
tion; e,  malleus  handle;/,  umbo;  g,  cone  of  light. 

stretched  obliquely  downward  and  inward  across  the  inner  end  of  the 
external  auditory  canal  forming  the  outer  wall  of  the  tympanic 
cavity.  The  drum  membrane  is  made  up  of  three  layers,  an  outer  one 
of  skin,  a  middle  of  fibrous  tissue,  and  an  inner  formed  by  the  reflec- 
tion of  the  mucous  membrane  of  the  middle  ear.  It  serves  the 
purpose  of  receiving  and  transmitting  sound  waves  to  the  chain  of 
ossicles. 

It  may  be  described  as  elliptical  in  outline,  and  of  a  pearly  gray 
color,  but  at  the  same  time  translucent.  Its  outer  surface  is  concave 
and  normally  smooth.  By  the  aid  of  a  speculum  and  suitable  illumi- 
nation there  will  be  noted  a  whitish  ridge  formed  by  the  handle  of  the 
malleus,  running  from  a  tubercle  near  the  upper  and  anterior  per- 
iphery downward  and  backward  toward  the  center  of  the  membrane. 
This  tubercle  represents  the  short  process  of  the  malleus.  Where  the 
handle  of  the  malleus  ends  near  the  center  of  the  membrane  is  a 
depression,  the  umbo.     Under  illumination  in  the  anterior  and  lower 


352  THE    EAR 

quadrant  of  the  drum  will  also  be  noted  a  triangular  area  of  light  (the 
reflection  of  light)  with  its  apex  at  the  tip  of  the  handle  and  its  base 
at  the  periphery  of  the  drum.  Extending  anteriorly  and  posteriorly 
from  the  short  process  of  the  malleus  are  two  delicate  folds  of  mem- 
brane which  divide  the  drum  into  two  portions.  That  portion  above 
these  folds  is  known  as  Shrapnell's  membrane,  or  the  membrana 
flaccida,  and  that  below  as  the  membrana  tensor. 

The  Eustachian  tube  is  a  canal  about  i  1/2  inches  (4  cm.)  long, 
connecting  the  pharynx  with  the  tympanic  cavity.  It  has  a  general 
direction  from  the  tympanum  forward,  downward,  and  inward, 
opening  upon  the  lateral  wall  of  the  pharynx  near  the  inferior  meatus 
of  the  nose  in  front  of  Rosenmiiller's  fossa  as  a  crater-like  eminence. 
The  tube  is  made  up  of  a  framework  which  in  the  outer  third  is  bony 
and  in  the  inner  two-thirds  cartilaginous  and  membranous,  and  is 
lined  with  ciliated  epithelium  which  waves  in  a  direction  toward  the 
pharynx.  The  two  ends  are  enlarged,  but  approaching  the  juncture 
of  the  osseous  and  cartilaginous  portions  the  tube  narrows  consider- 
ably. Normally  the  walls  are  in  apposition,  but  when  the  palatal 
muscles  contract,  as,  for  example,  in  the  act  of  swallowing  or  yawn- 
ing, the  walls  are  separated.  The  function  of  the  Eustachian  tube 
is  to  equalize  the  atmospheric  pressure  on  the  outer  and  inner  sides 
of  the  drum,  and  to  provide  drainage  for  the  tympanic  cavity  and 
mastoid  cells. 

Diagnostic  Methods 

A  complete  examination  of  the  ear  should  comprise  a  clinical  his- 
tory, an  examination  of  the  nasopharynx,  and  then  an  investigation 
of  the  ear  itself. 

A  history  is  quite  essential,  but  it  need  not  necessarily  be  an 
exhaustive  one.  It  should  first  be  ascertained  what  symptoms  or 
symptom  the  patient  complains  of,  and  whether  only  one  ear  or  both 
are  affected.  The  duration  of  the  trouble  is  also  of  importance,  as  it 
has  considerable  bearing  upon  the  prognosis  in  any  given  case.  The 
probable  cause  of  the  condition  should  also  be  determined  as  far  as 
is  possible  by  careful  questioning.  Among  the  many  etiological 
factors  of  ear  diseases  are  severe  colds,  grippe,  some  injury,  insects, 
acute  infectious  diseases,  syphilis,  tuberculosis,  etc.  The  symptoms 
or  symptom  complained  of  should  then  be  investigated  more  in  detail. 

Deafness  and  tinnitus  are  the  common  complaints  for  which  relief 
is  sought,  and  are  frequently  associated.     In  the  presence  of   the 


ANATOMIC   CONSIDERATIONS  353 

former  it  should  be  learned  whether  the  deafness  developed  slowly  or 
suddenly,  whether  one  or  both  ears  are  involved,  and,  if  the  latter  be 
the  case,  which  ear  is  more  affected.  The  duration  of  the  condition 
must  also  be  ascertained.  Not  infrequently  in  the  presence  of 
chronic  catarrh  of  the  middle  ear,  the  patient,  while  not  actually  deaf, 
will  complain  of  certain  disturbances  of  hearing,  as,  for  example,  the 
ability  to  hear  better  in  the  presence  of  noise,  as  on  a  railroad  train  or 
street  car  (paracusis  Willisii),  or  hearing  sounds  as  if  repeated  twice 
(paracusis  duplicata),  or,  again,  in  the  presence  of  marked  unilateral 
deafness  the  inability  to  locate  the  source  of  sounds  (paracusis 
localis) . 

Tinnitus,  or  subjective  noises,  are  present  in  middle-ear  diseases 
as  well  as  affections  of  the  internal  ear,  in  neurasthenic  conditions, 
arteriosclerosis,  and  may  follow  the  taking  of  certain  drugs,  as,  for 
example,  quinin  or  the  salicylates.  They  may  be  described  by  the 
patient  as  singing,  whisthng,  buzzing,  loud  and  roaring  or  musical 
in  character,  or  they  may  resemble  voices.  When  present,  it  should 
be  learned  whether  they  are  located  in  the  ear  or  in  the  head,  whether 
unilateral  or  bilateral,  and  whether  they  are  modified  by  mental  or 
physical  exertion  or  by  the  time  of  day.  As  a  rule  they  are  worse  at 
night,  and  in  some  cases  they  may  be  entirely  absent  during  the  day. 

In  the  presence  of  pain  or  earache,  its  character,  the  duration, 
and  whether  constant  or  intermittent  should  be  noted.  Pain  may  be 
the  result  of  morbid  conditions  in  the  ear  or  it  may  be  reflex,  as,  for 
example,  from  a  decayed  tooth,  or  from  an  inflammation  of  the 
pharynx,  tonsils,  etc.  When  it  suddenly  develops  in  an  ear  previously 
healthy  it  generally  points  to  an  acute  inflammation  of  the  middle  ear, 
while,  if,  on  the  other  hand,  it  occurs  during  the  course  of  some  chronic 
affection  of  the  ear,  a  coUection  of  fluid  in  the  middle  ear  or  destruc- 
tion of  bone  may  be  suspected.  Pressure  tenderness  is  also  of  diag- 
nostic importance  in  determining  the  origin  of  the  trouble.  Thus, 
pain  caused  by  traction  upon  the  auricle  or  by  pressure  on  the  tragus 
points  to  an  inflammation  involving  the  external  auditory  canal, 
tenderness  elicited  by  pressure  in  the  depression  below  the  lobule  of 
the  ear  to  middle-ear  inflammation,  and  pressure  tenderness  over  the 
mastoid  to  involvement  of  that  bone. 

The  presence  or  absence  of  a  discharge  is  next  determined.  With 
a  history  of  a  discharging  ear,  the  length  of  time  the  discharge  has 
lasted,  the  character  of  the  discharge,  whether  serous,  bloody,  or 
purulent,  whether  scanty  or  in  large  amounts  and  whether  continuous 
or  intermittent  should  be  noted.  It  is  also  important  to  ascertain  if 
23 


354  THE    EAR 

the  discharge  is  accompanied  by  pain,  and  the  relation  the  pain  and 
the  discharge  bear  to  one  another. 

In  addition  to  the  above  points,  the  occupation  and  habits  of  the 
patient  should  be  investigated  as  having  an  etiological  bearing  upon 
the  case,  and  in  certain  cases  a  general  physical  examination  should  be 
made.  One  should  never  fail  to  investigate  the  condition  of  the  nose 
and  throat,  especially  the  nasopharynx,  noting  the  presence  or 
absence  of  congestion,  swelling  of  the  mucous  membrane,  adenoid 
growths,  ulcers,  etc.,  and  the  condition  of  the  pharyngeal  ends  of  the 
Eustachian  tubes.  The  technic  of  such  examination  has  already  been 
described  in  Chapter  XIII.  The  parts  in  the  vicinity  of  the  ear 
should  likewise  be  inspected  as  well  as  palpated  for  signs  of  inflamma- 
tion, swellings,  new  growths,  enlarged  glands,  or  signs  of  tenderness. 
Having  completed  these  preliminaries,  the  actual  examination  of  the 
ear  should  be  instituted. 

The  examination  of  the  ear  comprises  (i)  direct  inspection  of  the 
external  ear,  (2)  inspection  of  the  external  auditory  canal  and  tym- 
panic membrane  by  the  aid  of  specula,  (3 )  determination  of  the 
mobility  of  the  drum  membrane,  (4)  various  tests  of  the  power  of 
hearing,  and  (5)  determination  of  the  patency  of  the  Eustachian 
tubes.  la  all  cases  the  examiner  should  not  fail  to  investigate  the 
condition  of  both  ears. 

DIRECT  INSPECTION 

A  thorough  inspection  of  the  auricle  and  external  auditory  canal 
should  always  precede  the  use  of  a  speculum.  In  this  way  the  exam- 
iner may  be  enabled  to  recognize  pathological  conditions  at  the 
entrance  of  the  auditory  canal  that  might  otherwise  escape  attention 
or  be  hidden  from  view  by  the  speculum. 

Instruments. — All  that  is  required  is  suitable  illumination.  This 
may  be  furnished  by  means  of  an  electric  head  light  (see  Fig.  311),  or 
by  means  of  light  reflected  upon  the  part  by  means  of  a  head  mirror. 

Position  of  Patient. — The  patient  is  seated  upon  a  stool  with  the 
ear  to  be  examined  turned  toward  the  surgeon,  who  is  also  seated  upon 
a  stool  of  such  height  that  his  eyes  are  on  a  level  with  the  ear  of  the 
patient.  If  reflected  light  is  employed,  the  source  of  illumination 
should  be  a  little  above  the  level  of  the  patient's  ear  and  upon  the 
examiner's  left  side. 

Technic. — Under  full  illumination  the  auricle  is  first  carefully 
inspected,  noting  the  presence  or  absence  of  excoriations  from  dis- 


OTOSCOPY 


355 


charges,  eczema,  swellings,  deformities,  new  growths,  etc.  Then  by 
means  of  traction  upon  the  auricle  in  an  upward  and  backward  direc- 
tion, the  external  auditory  canal  is  straightened  out  and  a  view  of  a 
considerable  portion  of  its  interior  becomes  possible.  The  examiner 
should  note  especially  the  color  of  the  canal  for  signs  of  inflammation, 
the  presence  or  absence  of  swellings,  fissures,  foreign  bodies,  new 
growths,  etc. 


OTOSCOPY 

Otoscopy  is  the  inspection  of  the  external  auditory  canal  and 
tympanic  membrane  by  the  aid  of  a  speculum  and  suitable  illumina- 
tion. By  this  means  parts  of  the  auditory  canal  and  the  drum  mem- 
brane invisible  to  direct  inspection  may  be  viewed  in  detail,  and  the 
presence  or  absence  of  pathological  conditions  recognized. 

Instruments. — There  will  be  required  a  strong  light,  such  as  is 
obtained  from  a  Welsbach  burner  covered  by  a  Mackenzie  condenser, 


Fig.  365. — Instruments  for  otoscopy,      i,    Head  mirror;  2,  aural  specula;  3,  ear 
probe;  4,  ear  curet;  5,  angular  ear  forceps;  6,  ear  syringe. 

mounted  upon  an  adjustable  bracket  so  that  it  may  be  raised  to  any 
desired  height,  a  concave  head  mirror  3  1/2  to  4  inches  (9  cm. 
to  10  cm.)  in  diameter  with  a  central  perforation  for  the  eye,  three 
sizes  of  metal  aural  specula,  a  fine  ear  curet,  a  probe,  a  pair  of 
PoUtzer  angular  ear  forceps,  and  an  ear  syringe  (Fig.  365).  If 
desired,  in  place  of  reflected  light,  illumination  from  an  electric  head 
light  may  be  substituted. 

For  purposes  of  examination  Gruber's  specula  (Fig.  366)  are  most 
satisfactory,  as  they  are  elliptical  in  shape  upon  transverse  section 
thus  corresponding  to  a  transverse  section  of  the  external  auditory 
canal.  Where,  however,  operative  procedures  are  indicated  a  spec- 
ulum with  a  wide  proximal  end  that  will  permit  the  manipulation  of 


356 


THE    EAR 


instruments,  such  as  Boucheron's  (Fig.  367)  or  Toynbee's  is  prefer- 
able. Electric-lighted  specula^  (Fig.  368)  are  now  used  to  a  large 
extent,  and  simplify  the  operation  considerably. 

Asepsis. — To  avoid  carrying  infection  from  one  patient  to  another 
the  instruments  employed  in  otoscopy  should  be  boiled  or  immersed 


Fig.  366. — Gruber's  speculum. 


Fig.  367. — Boucheron's  speculum. 


in  a  I  to  20  carbolic  acid  solution  and  then  rinsed  in  sterile  water 
and  dried  before  use. 

Position  of  Patient. — The  patient  and  examiner  should  be  seated, 
the  former  with  the  ear  turned  toward  the  examiner.  The  examiner's 
eyes  should  be  on  a  level  with  the  patient's  ear  and  in  a  horizontal 


Fig.  368.— Electric-lighted  speculum. 

plane  with  the  external  auditory  canal.  If  reflected  light  is  employed, 
the  source  of  illumination  should  be  a  little  above  the  level  of  the 
patient's  ear  and  upon  the  examiner's  left. 

^  Manufactured  by  the  Electro-Surgical  Instrument  Co.  of  Rochester,  N.  Y. , 
and  the  Wappler  Co.,  New  York  City. 


OTOSCOPY 


357 


Technic. — The  examiner  directs  the  light  full  upon  the  external 
auditory  meatus  and,  grasping  the  auricle  between  the  thumb  and 
index  finger  of  the  left  hand  (if  the  right  ear  is  being  examined  and 
vice  versa),  makes  traction  in  an  upward,  backward,  and  slightly 
outward  direction,  to  straighten  out  the  auditory  canal.  In  infants, 
to  accomplish  this,  it  is  necessary  to  pull  the  auricle  outward  and  a  lit- 
tle downward,  as  the  wall  of  the  canal  has  no  bony  support  at  this 
time  and  lies  collapsed  against  the  side  of  the  head.  The  speculum  is 
then  warmed  and,  grasped  by  its  rim  between  the  thumb  and  index 
finger  of  the  right  hand,  it  is  gently  introduced  by  a  slight  rotary 
motion  until  it  has  passed  the  junction  of  the  cartilaginous  and  bony 
portions  of  the  canal.  In  inserting  the  instrument,  care  must  be 
taken  to  follow  the  long  axis  of  the  auditory  canal,  by  watching  the 


Fig.  369. — Otoscopy  with  the  reflector  and  ear  specuhim. 
course  of  light.     (Gleason.) 


The  arrows  represent 


parts  illuminated  at  the  distal  end  of  the  speculum  until  the  drum 
membrane  is  brought  to  view.  With  the  speculum  properly  in  place, 
the  left  hand  is  shifted  from  the  auricle  to  hold  the  speculum,  the  right 
hand  being  thus  left  free  to  manipulate  any  instruments  (Fig.  369). 
Before  examining  the  drum  membrane,  the  external  auditory 
canal  should  be  inspected,  noting  its  color,  size  and  shape,  and  the 
presence  or  absence  of  foreign  bodies,  polypi,  discharges,  secretions, 
or  cerumenous  plugs.  Signs  of  inflammation  and  furuncles  should 
also  be  looked  for.  Sometimes  secretions  and  collections  of  wax 
require  removal  before  inspection  is  possible.  This  may  be  accom- 
plished, as  a  rule,  by  gently  syringing  the  canal  with  warm  saline 


i58 


THE   EAR 


solution  or  a  saturated  solution  of  boric  acid  (see  page  370).  Small 
masses  of  wax  and  flakes  may  require  removal  by  means  of  the  curet, 
followed  by  gentle  syringing.  The  ear  is  then  thoroughly  dried  by 
means  of  small  mops  of  sterile  cotton  held  in  angular  forceps  or 
wrapped  about  the  tip  of  a  probe. 

The  examiner  next  inspects  the  drum  membrane.  It  is  placed  at 
the  distal  end  of  the  canal,  inclining  downward  and  inward  at  an  angle 
of  about  45  degrees.  The  normal  drum  appears  translucent  and  of  a 
pearly  gray  color,  with  its  circumference  appearing  as  a  white  line. 
Extending  from  above  downward  and  backward  in  the  upper  half  of 
the  drum  is  seen  the  handle  of  the  malleus.  In  the  upper  and  anterior 
portion  about  1/25  inch  (i  mm.)  from  the  superior  wall  is  the  short 
process  of  the  malleus,  and  running  forward  and  backward  above  the 
short  process  are  two  folds  of  membrane  above  which  lies  Shrapnell's 
membrane.  Extending  from  the  tip  of  the  malleus  toward  the  per- 
phery,  in  the  lower  and  anterior  quadrant,  will  be  noted  the  bright 


Fig.  370. — The  appearance  of  the  drum  membrane  as  seen  through  the  specukim. 

cone  of  reflected  light.  In  addition  to  these  landmarks  normally  to 
be  observed,  if  the  membrane  is  very  thin  and  retracted,  there  may  be 
seen  the  long  process  of  the  incus  as  a  whitish  line  running  down 
behind  and  parallel  to  the  handle  of  the  malleus. 

On  inspection  of  the  drum  membrane,  one  should  note  first  its 
color,  whether  congested  and  red  and  if  uniformly  so,  also  whether 
translucent,  as  it  normally  should  be,  or  thickened  and  exhibiting 
localized  opacities.  The  presence  or  absence  of  granulations  or 
perforations  should  also  be  determined,  the  latter  being  evidenced  by 
the  greater  depth  of  the  drum  at  the  point  of  perforation.  Note  also 
if  the  membrane  is  retracted  or  bulging  with  fluid.  If  retracted,  the 
short  process  of  the  malleus  appears  more  plainly,  the  handle  is  short- 


DETERMINATION    OF    MOBILITY    OF    DRUM    MEMBRANE  359 

ened,  and  the  conical  folds  are  deepened.  At  the  same  time  the  cone 
of  reflected  Hght  will  appear  altered  in  shape  and  displaced.  If  bulg- 
ing is  present,  its  location  should  be  noted.  As  a  rule,  bulging  occurs 
in  the  posterior  portion  of  the  membrane,  or  the  entire  drum  may  be 
distended.  If  it  occurs  in  the  upper  portion  only,  involvement  of 
the  attic  is  present.  By  changing  the  position  of  the  speculum 
slightly  all  portions  of  the  drum  may  be  viewed  in  detail.  By  means 
of  a  cotton-tipped  probe,  inspection  may  be  supplemented  by  careful 
palpation,  if  further  information  as  to  the  conditions  found  is  desired. 
In  all  manipulations  of  the  speculum  or  instruments  great  gentleness 
should  be  observed. 

DETERMINATION  OF  THE  MOBILITY  OF  THE  DRUM 
MEMBRANE 

By  the  aid  of  a  pneumatic  otoscope  with  which  the  air  in  the  exter- 
nal auditory  canal  may  be  alternately  condensed  or  rarefied,  it  is  pos- 
sible to  determine  the  degree  of  mobility  possessed  by  the  membrana 


Fig.  371. — Siegle's  pneumatic  otoscope. 

tympani,  and  thus  recognize  undue  rigidity  or  laxness  of  the  drum  or 
the  existence  of  intratympanic  adhesions  binding  the  drum  or  ossicles 
to  the  walls  of  the  tympanum. 

Apparatus. — Siegle's  pneumatic  otoscope  (Fig.  371)  consists  of 
an  air-tight  chamber,  the  proximal  end  of  which  is  closed  by  a  plain 
glass  window  or  convex  lens  placed  at  an  angle  of  45  degrees  to  the 
long  axis  of  the  instrument,  while  to  the  distal  end  may  be  screwed 
different  sized  specula.  Upon  the  side  of  the  air-tight  chamber  is 
placed  a  small  perforated  knob  to  which  is  attached  a  piece  of  rubber 
tubing  and  a  hand  bulb.  The  instrument  may  be  obtained  with  an 
electric  light  in  its  interior  or  illumination  may  be  supplied  by  an 
electric  head  light  or  reflected  light  from  a  head  mirror. 


360  THE    EAR 

Position  of  Patient. — The  patient  and  the  operator  occupy  the 
same  relative  positions  as  employed  for  an  ordinary  otoscopic  exam- 
ination (see  page  356) . 

Asepsis. — The  speculum  portion  of  the  instrument  should  be 
sterilized  by  boiling. 

Technic. — Some  of  the  air  is  expelled  from  the  bag  which  is  held 
in  the  examiner's  right  hand,  and  the  instrument  is  fitted  snugly  into 
the  auditory  canal  in  the  same  manner  as  an  ordinary  speculum.  A 
small  piece  of  rubber  tubing  may  be  slipped  over  the  end  of  the  specu- 
lum, if  necessary,  to  insure  its  fitting  the  auditory  canal  more  accu- 
rately. The  examiner  then  observes  under  good  illumination  the 
movement  of  the  drum  membrane  through  the  window  in  the  oto- 
scope, as  he  relaxes  or  compresses  the  bulb.  As  the  air  is  rarefied,  the 
drum  is  sucked  outward  and  becomes  convex  in  shape.  As  the  air 
is  condensed  by  compression  of  the  bulb,  the  drum  membrane 
moves  inward  and  becomes  more  concave.  The  presence  of  adhe- 
sions will  be  evidenced  by  absence  of  any  mobility  at  that  particu- 
lar point,  while  other  parts  of  the  drum  will  move  freely.  Too  ener- 
getic use  of  the  instrument  must  be  avoided  for  fear  of  rupturing 
a  weakened  drum. 

HEARING  TESTS 

Hearing  tests  are  very  important  in  the  diagnosis  of  ear  diseases, 
since  they  not  only  furnish  information  as  to  the  extent  the  hearing  is 
impaired,  but  also  serve  to  localize  the  seat  of  a  lesion,  that  is,  whether 
in  the  conducting  apparatus  or  in  the  nervous  mechanism.  While 
there  have  been  a  number  of  hearing  tests  devised,  the  following  are 
sufficient  for  all  practical  purposes:  (i)  testing  the  acuteness  of  hear- 
ing by  means  of  the  watch  and  voice,  (2)  testing  the  perception  of  high 
and  low  notes,  (3)  Weber's,  and  (4)  Rinne's  test. 

Apparatus. — While  it  is  of  advantage  to  have  a  complete  set  of 
tuning-forks,  the  ordinary  tests  may  be  carried  out  with  a  low  tone 
fork  (C-2)  having  thirty-two  vibrations  per  second,  a  Galton's  whistle 
for  high  tones,  and  a  C  2  fork  having  512  vibrations  per  second 
for  Weber's  and  Rinne's  tests.  Galton's  whistle  gives  tones  ranging 
from  about  7000  vibrations  per  second  to  the  highest  perceptible  tone 
limit.  The  instrument  is  provided  with  a  scale  and  screw  whereby 
the  nimiber  of  vibrations  may  be  regulated  so  as  to  give  any  tone 
wnthin  the  Hmits  stated  above. 

Tests  of  the  Acuteness  of  Hearing. — i.  The  Watch  Test. — The 
test  is  made  in  a  room  free  from  noise  and  with  a  watch  that  ticks 


HEARING    TESTS 


361 


rather  loudly.  Since  the  ticking  of  different  watches  varies  con- 
siderably, the  distance  at  which  the  particular  watch  is  heard  by  a 
normal  ear  must  be  determined  by  experience.  Each  ear  is  tested 
separately  in  the  following  manner:  The  patient  is  seated  in  a  chair 


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/  V 


c. 


Pig.  372. — Hartmann's  set  of  tuning-forks  vanning  from  128  vs.  to  2048  vs. 

with  his  eyes  closed,  and  with  his  forefinger  closing  the  ear  not  under 
examination.  The  examiner  first  holds  the  ticking  watch  close  to 
the  ear  being  tested  so  that  the  patient  can  hear  it  distinctly  and  then 
slowdy  brings  it  from  a  distance  beyond  the  range  of  hearing  power 
toward  the  ear  in  a  line  perpendicular  to  the  auricle  until  the  patient 


Fig.  373. — Edelmann's  modification  of  Galton's  vv-histle. 

again  recognizes  the  ticking.  The  distance  from  the  ear  at  which  the 
ticking  is  heard  is  then  accurately  measured,  and  the  result  is 
expressed  in  a  fraction  of  inches,  the  denominator  of  which  represents 
the  number  of  inches  at  which  the  particular  watch  is  normally  heard 


362  THE    EAR 

and  the  numerator  the  number  of  inches  it  is  heard  by  the  ear  under 
examination.  For  example,  if  the  watch  is  heard  at  forty  inches  (100 
cm.)  by  the  normal  ear  and  the  patient  hears  it  at  ten  inches  (^25  cm.) 
the  result  is  expressed  as  10/40. 

2.  The  Voice  Test. — The  patient  is  seated  in  a  large  room  with  the 
eyes  closed  and  the  ear  not  under  examination  plugged  with  the  fore- 
finger. The  examiner  then  repeats  words  of  one  syllable  or  numerals 
in  an  ordinary  voice  and  also  in  a  whisper  at  the  end  of  expiration  with 
the  residual  air  from  various  distances,  and  measures  the  distance  at 
which  the  patient  can  hear  and  repeat  them  correctly.  The  result  is 
expressed  in  a  fraction  of  feet,  the  denominator  of  which  represents 
the  distance  in  feet  at  which  the  normal  ear  can  hear  the  voice  and 
the  numerator  the  actual  distance  at  which  it  is  heard  by  the  ear 
under  examination.  In  employing  this  test  it  is  important  that 
the  patient  does  not  see  the  lips  of  the  examiner  and  that  the  sounds 
are  transmitted  to  the  ear  under  examination  at  right  angles  to  the 
auricle. 

Testing  the  Perception  of  Different  Notes. — The  normal 
range  of  hearing  in  adults  for  musical  notes  lies  between  16  and  48,000 
vibrations  per  second.  The  majority  of  individuals,  however,  possess 
a  more  Kmited  range  than  this,  varying  from  about  24  to  16,000  vibra- 
tions per  second.  In  this  test  the  hearing  is  tested  for  low  tones  with 
a  low-toned  fork  and  for  high  tones  with  the  Galton  whistle.  The 
test  is  of  diagnostic  value  in  differentiating  between  disturbance  of 
hearing  due  to  affections  of  the  conducting  and  those  of  the  percep- 
tive apparatus.  Where  the  conduction  apparatus  is  at  fault  high 
tones  are  heard  better  than  low,  while  in  diseases  of  the  perceptive 
apparatus,  the  low  tones  are  heard  well,  but  high-tone  hearing  is  lost 
or  diminished.  It  should  be  remembered,  however,  that  in  advancing 
age  the  upper  tone  limit  is  lowered. 

Weber's  Test. — It  is  employed  for  the  purpose  of  locating  the 
seat  of  unilateral  deafness.  In  this  test  a  C  2  (512  vs.)  fork  is  set 
vibrating  and  the  handle  is  placed  on  the  incisor  teeth  or  upon  the 
cranium  in  the  mid-line.  If  the  sound  is  heard  best  in  the  affected 
ear.  it  is  indicative  of  some  aft'ection  of  the  conduction  apparatus,  as 
middle-ear  disease,  impacted  cerumen,  or  occlusion  of  the  Eustachian 
tube,  while  if  the  perceptive  apparatus  is  at  fault,  it  will  be  heard 
better  in  the  normal  ear. 

Rinn6's  Test.- — This  test  depends  upon  the  fact  that  aerial  con- 
duction is  better  than  bony  conduction.  In  a  normal  ear.  if  a  C  2 
(512  vs.)  fork  be  placed  upon  the  mastoid  until  the  patient  no  longer 


IXFLATIOX  OF  THE  MIDDLE  EAR  363 

"hears  any  sound,  and.  if  the  fork  is  then  brought  close  to  the  external 
ear.  the  sound  will  again  be  heard.  This  is  known  as  a  positive  Rinne. 
If.  however,  the  sound  is  not  heard  again  when  the  fork  is  thus  trans- 
posed, it  is  known  as  a  negative  Rinne.  Therefore,  in  a  deaf  ear,  if 
we  obtain  a  positive  Rinne,  it  is  indicative  of  a  lesion  in  the  perceptive 
apparatus,  while  if,  under  the  same  conditions,  the  test  is  negative, 
it  shows  that  bony  conduction  is  increased;  i.e.,  there  is  some  obstruc- 
tion or  disease  of  the  conduction  apparatus. 

INFLATION  OF  THE  MIDDLE  EAR 

Inflation  of  the  middle  ear  has  both  diagnostic  and  therapeutic 
value.  As  a  diagnostic  measure  it  is  employed  to  determine  the  pat- 
encv  of  the  Eustachian  tubes,  that  is,  whether  or  not  an  unobstructed 
communication  exists  between  the  middle  ear  and  the  pharynx;  for 
the  purpose  of  detecting  the  presence  or  absence  of  an  exudate  in  the 
middle  ear,  and.  if  so.  the  character  of  the  exudate;  to  detect  the  pres- 
ence of  a  perforation  of  the  membrana  tympani;  and  to  determine  the 
mobility  of  the  membrana  tympani.  The  therapeutic  uses  of  infla- 
tion will  be  considered  later  (see  page  376). 

An  auscultatory  tube  is  employed  in  conjunction  with  inflation 
for  the  purpose  of  determining  whether  air  enters  the  middle  ear  and 
to  distinguish  the  character  of  the  sound  produced  which  is  of  diag- 
nostic importance.  Thus,  in  a  normal  condition  of  the  Eustachian 
tubes  and  tympanic  cavity,  air  -^^11  be  heard  to  enter  the  middle  ear 
with  a  soft  blowing  sound;  if  the  tube  be  obstructed,  the  sound  will 
have  a  more  or  less  whistling  character,  while,  if  the  obstruction  is  not 
overcome,  air  will  not  be  heard  to  enter  the  middle  ear  at  all  and  the 
sound  wiU  be  distant.  When  the  middle  ear  contains  an  exudate,  the 
sound  will  vary  according  to  the  character  of  the  fluid;  if  it  is  thin 
and  watery,  a  flne  bubbflng  sound  will  be  heard;  if  it  is  thick  and 
\'iscid,  the  sound  wiU  be  a  coarse  bubbling  one.  In  the  presence  of  a 
perforation  of  the  membrana  tympani,  inflation  causes  a  characteris- 
tic hissing  or  whistHng  sound  and  often  secretion  will  be  forced  out 
through  the  perforation  into  the  external  auditory  canal.  By  the  aid 
of  a  speculum,  the  drum  may  be  inspected  and  the  efl'ect  of  the  infla- 
tion upon  it  noted  and  the  mobihty  determined. 

There  are  three  methods  by  which  the  middle  ear  may  be  inflated: 
(i)  Valsalva's  method,  (2)  PoKtzer's  method,  and  (3)  catheteriza- 
tion. Before  practising  inflation  it  is  a  wise  precaution  to  inspect  the 
ear-drum  to  see  if  it  is  suf&ciently  strong  to  stand  the  strain,  as  cases 


364  THE    EAR 

have  been  reported  where  a  diseased  drum  has  been  ruptured  by  the 
Politzer  bag. 

Position  of  Patient. — The  patient  should  be  seated  upon  a  chair. 
The  examiner  is  also  seated,  facing  the  patient. 

Preparations  of  Patient. — In  all  cases  the  nose  and  pharynx  should 
be  thoroughly  cleansed  before  inflation  is  performed  by  means  of 
gargling  and  the  use  of  a  nasal  spray  (page  330). 

Valsalva's  Method. — This  method  of  inflation  is  the  simplest  of 
the  three  and  at  the  same  time  is  the  least  reliable.  It  is  fairly 
successful,  however,  if  only  a  slight  obstruction  exists.  On  account 
of  the  ease  with  which  it  can  be  performed  by  the  patient,  it  is  apt  to 
be  repeated  too  frequently,  wath  the  risk  of  producing  a  flaccid  con- 
dition of  the  drum  unless  the  patient  is  cautioned  against  its  overuse. 

Apparatus. — There  will  be  required  a  head  mirror  and  some 
source  of  illumination,  or  an  electric  head  light,  aural  specula,  and  an 


Fig.  374.. — Aural  stethoscope. 

aural  stethoscope.  The  latter  instrument  (Fig.  374)  consists  of  a 
piece  of  rubber  tubing,  about  3  feet  (90  cm.)  long  into  the  two  ends  of 
which  are  fitted  hard-rubber  ear-pieces — a  white  one  for  the  exam- 
iner's ear  and  a  black  one  to  fit  into  the  patient's  ear. 

Asepsis. — The  specula  and  ear  pieces  of  the  aural  stethoscope 
should  be  sterile. 

Technic. — The  patient's  mouth  should  be  shut  and  the  nostrils 
held  closed  by  the  fingers.  Then  the  patient  is  instructed  to  give  a 
forced  expiration  and  at  the  same  time  swallow.  The  act  of  swallow- 
ing causes  the  tubes  to  relax,  and  the  air,  under  pressure,  is  thus 
forced  through  the  tubes  into  the  middle  ear.  As  this  occurs  the 
patient  will  have  a  feehng  of  distention  in  both  ears,  and  the  exam- 
iner by  means  of  the  aural  stethoscope  will  hear  the  sound  of  air  en- 
tering the  middle  ear.  If  the  drum  membrane  is  inspected  as  the 
inflation  is  performed,  it  will  be  noticed  that  the  membrane  moves 
outward  and  becomes  somewhat  congested. 


INFLATION  OF  THE  MIDDLE  EAR 


365 


Politzer's  Method. — This  is  probably  the  most  frequently 
employed  method  of  inflation. 

Apparatus. — There  will  be  required  a  head  mirror  and  suitable 
illumination  or  an  electric  head  light,  aural  specula,  an  aural  stetho- 
scope, and  a  PoUtzer  air-bag  (Fig.  375).  The  Politzer  air-bag  con- 
sists of  a  soft  pear-shaped  bag  of  such  size  and  shape  that  it  can  be 
readily  compressed  in  the  operator's  hand,  supphed  with  a  piece  of 
rubber  tubing  about  8  inches  (20  cm.)  long,  to  the  end  of  which  is 
attached  an  olive-shaped  glass  nose-piece. 

Asepsis. — The  glass  nose-piece  and  the  specula  should  be  sterilized 
by  boiling  before  use.  The  ear  pieces  of  the  aural  stethoscope  should 
also  be  sterile. 

Technic. — The  patient  is  first  given  a  small  amount  of  water — 
about  a  teaspoonful  is  sufficient — which  he  is  instructed  to  hold  in  his 


Fig.    375. — Instruments  for  Politzer's  method  of  inflation.       i,  Head  mirror;  2, 
aural  specula;  3,  aural  stethoscope;  4,  Politzer  inflation  bag. 


mouth  until  told  to  swallow.  The  examiner  then  inserts  the  nose- 
piece  of  the  PoHtzer  bag  into  one  nostril  for  a  distance  of  about 
1/2  inch  (i  cm.),  and  compresses  both  nostrils  about  it  by  means  of 
the  left  thumb  and  forefinger.  The  patient  is  then  told  to  swallow, 
and,  as  the  larynx  is  seen  to  rise  up  at  the  commencement  of  the  act 
of  swallowing,  the  examiner  compresses  the  air-bag  with  his  right 
hand  (Fig.  376).  The  act  of  swallowing  causes  the  soft  palate  to  rise 
upward  and  shut  oft'  the  naso-pharynx,  and,  at  the  same  time,  the 
Eustachian  tubes  tend  to  open  so  that  the  air  is  readily  forced  through 
the  tubes  into  the  middle  ear.  In  children  crying  has  the  same 
eft'ect  as  swallowing. 

With  the  auscultatory  tube  the  character  of  the  sound  produced 
is  recognized.  When  it  is  desired  to  inflate  only  one  ear,  the  patient's 
head  should  be  turned  to  one  side,  so  that  the  aft'ected  ear  lies  upper- 


366 


THE   EAR 


most,  while  at  the  same  time  the  opposite  ear  is  closed  by  the  fingers 
pressed  against  the  external  auditory  meatus.  In  using  Politzer's 
bag  care  should  be  taken  not  to  use  a  great  amount  of  force  and 
thereby  avoid  causing  the  patient  pain. 

Catheterization. — Inflation  through  an  Eustachian  catheter  is 
only  indicated  when  inflation  by  the  methods  previously  mentioned  is 
impossible.  The  passage  of  a  catheter  into  the  Eustachian  tube  is  a 
delicate  operation  requiring  skill  as  well  as  gentleness  of  touch  for  its 
safe  and  successful  performance.  If  carelessly  performed,  there  is 
danger  of  injuring  the  mucous  lining  of  the  tube  or  of  making  a  false 
passage  and  injecting  air  into  the  submucous  tissues  of  the  tube,  an 


Fig.  376. — Inflation  by  Politzer's  method. 


accident  from  which  deaths  from  respiratory  obstruction  have  been 
reported.  In  certain  cases  it  may  be  impossible  to  perform  catheteri- 
zation, as,  for  example,  in  the  presence  of  marked  deviations  of  the 
septum,  considerable  narrowing  of  the  nasal  fossae,  tumors,  or  ade- 
noids, and  in  nervous  or  hysterical  individuals  or  in  those  upon  whom 
attempts  to  pass  the  catheter  excite  coughing,  retching,  or  spasm  of 
the  pharyngeal  muscles. 

Apparatus. — There  will  be  required  a  head  mirror  and  suitable 
illumination  or  an  electric  head  Hght,  aural  specula,  an  aural  stetho- 
scope, a  Politzer  air-bag  with  an  Eustachian  catheter  tip,  and  several 
sizes  of  Eustachian  catheters  (Fig.  377).  The  catheter  is  a  metal 
tube  6  1/2  inches  (16  cm.)  long,  curved  at  its  distal  end,  the  extreme 
tip  of  which  is  slightly  bulbous,  and  with  an  expanded  proximal  end 


IXPLATIOX  OF  THE  MIDDLE  EAR 


367 


into  which  the  tip  of  a  PoHtzer  bag  may  be  fitted.  It  should  be  of 
pure  silver  so  that  its  curve  may  be  changed  to  fit  the  individual  case. 
A  ring  is  placed  upon  the  side  of  the  instrument  near  its  proximal 
end  to  indicate  the  direction  of  the  beak.  Three  sizes  should  be  pro- 
vided 1/25,  1/12,  1/8  inch  (i,  2,  and  3  mm.)  in  diameter,  respectively. 

Asepsis. — The  catheter  and  the  specula  should  be  sterilized  by 
boiling;  the  ends  of  the  aural  stethoscope  should  be  likewise  sterile,, 
and  the  hands  of  the  operator  should  be  cleansed  as  for  any  operative 
procedure. 

Anesthesia. — In  sensitive  individuals  the  nose  may  be  anesthe- 
tized by  means  of  a  small  amount  of  a  4  per  cent,  solution  of  cocain 
apphed  by  means  of  a  cotton-tipped  probe  to  the  inferior  meatus. 


=^ 


Fig.  377. — Instruments  for  inflation  through  an  Eustachian  catheter,  i,  Head 
mirror;  2,  aural  specula;  3,  aural  stethoscope;  4,  Politzer's  inflation  bag;  5,  Eusta- 
chian catheters. 


Technic. — The  operator  fijst  inspects  the  nose  by  the  aid  of 
illumination  for  the  presence  of  deviations  of  the  septum  or  other 
pathological  conditions  which  might  interfere  with  the  passage  of  the 
catheter.     The  catheter  may  then  be  inserted  by  one  of  two  methods : 

I.  Louenherg  Method. — The  proximal  end  of  the  lubricated  cathe- 
ter is  grasped  Hghtly  between  the  thumb  and  forefinger  of  the  right 
hand,  while  by  means  of  the  thumb  of  the  left  hand,  the  tip  of  the 
patient's  nose  is  elevated  so  as  to  straighten  out  the  canal.  The 
beak  of  the  instrument  is  then  introduced  within  the  anterior  nares, 
the  shaft  of  the  instrument  being  in  an  almost  vertical  position  (Fig. 
378).  The  catheter  is  then  elevated  to  a  horizontal  position,  and, 
with  the  tip  kept  constantly  in  contact  with  the  floor  of  the  nose,  it  is 
gently  pushed  inward  until  the  beak  comes  in  contact  mth  the  pos- 
terior wall  of  the  pharynx  (Fig.  379).     The  beak  is  then  rotated 


368 


THE   EAR 


through  an  angle  of  90  degrees  toward  the  median  line,  until  the  guide 
ring  lies  horizontal,  and  the  catheter  is  drawn  forward  until  its  beak 
is  found  to  impinge  upon  the  nasal  septum  (Fig.  380).     The  beak  is 


Fig.  378. — Catheterizing  the  Eustachian  tube.     First  step,  showing  the  position 
of  the  catheter  for  its  introduction. 


Fig.  379. — Catheterizing    the    Eustachian    tube.     Second    step,    catheter    being 
passed  along  the  floor  of  the  nose. 

then  rotated  downward  and  outward  through  an  angle  of  a  little 
more  than  180  degrees  until  the  guide  ring  points  toward  the  outer 


INFLATION  OF  THE  MIDDLE  EAR 


369 


can  thus  of  the  eye;  at  the  same  time  the  proximal  end  of  the  catheter 
is  moved  toward  the  nasal  septum,  and  its  tip  thus  enters  the  Eu- 
stachian tube  (Fig.  381).     In  all  these  manipulations  care  should  be 


Fig.  380. — Showing  the  different  positions  of  the  beak  of  the  catheter  in  its  in- 
sertion into  the  orifice  of  the  Eustachian  tube.     (After  Barnhill  and  Wales.) 

taken  to  employ  the  greatest  gentleness.  The  entrance  of  the 
catheter  into  the  tube  will  be  recognized  by  the  fact  that  the  tip  is 
firmly  fixed  and   cannot  be  rotated.     The   catheter  is  now  held 


Fig.  381. — Catheterizing  the  Eustachian  tube.     Third  step,  showing  the  position 
of  the  guide  when  the  catheter  tip  is  entering  the  orifice  of  the  tube. 

in  place  by  the  thumb  and  forefinger  of  the  left  hand,  the  other  fin- 
gers resting  upon  the  bridge  of  the  nose,  and,  with  the  nozzle  of  the 
air-bag  fitted  into  the  proximal  end  of  the  catheter,  inflation  is  per- 
24 


37° 


THE    EAR 


formed  by  compressing  the  bag  in  the  fingers  of  the  right  hand  (Fig. 
382).  While  this  is  done  the  examiner  notes  the  sound  produced  by 
means  of  the  auscultation  tube. 

In  removing  the  catheter  it  is  first  rotated  until  its  back  points 
downward  and  is  then  gently  withdrawn  by  a  reversal  of  the  move- 
ments employed  in  its  insertion. 

2.  Binnajont  or  Kramer  Method. — The  instrument  is  introduced 
in  the  same  manner  as  described  under  the  Lowenberg  method  until 
the  beak  is  in  contact  with  the  posterior  pharyngeal  wall.  The 
beak  is  then  rotated  outward  through  more  than  an  angle  of  90  degrees 
which  causes  its  tip  to  rest  in  Rosenmiiller's  fossa.     The  catheter  is 


Fig.  382. — Inflation  through  an  Eustachian  catheter.      (Gleason.) 


then  withdrawn  until  its  tip  is  felt  to  slip  over  the  bulging  posterior 
lip  of  the  Eustachian  mouth  when  its  tip  will  be  at  the  pharyngeal 
orifice  of  the  tube.  The  distance  it  is  necessary  to  withdraw  the 
catheter  to  accomplish  this  varies  usually  between  1/4  to  3/8  inch 
(6  to  9  mm.) .  The  catheter  is  then  rotated  until  the  guide  ring  points 
to  the  outer  canthus  of  the  eye  and  the  tip  slips  into  the  tube.  With 
the  catheter  in  position  inflation  is  performed  as  described  above. 


Therapeutic  Measures 
THE  EAR  SYRINGE 

Syringing  of  the  ear  is  employed  for  the  purpose  of  removing 
foreign  bodies  or  cerumenous  masses  from  the  external  auditory  canal 


THE    EAR    SYRINGE 


371 


and  to  keep  the  ear  free  from  purulent  material  which  collects  after 
perforation  or  incision  of  the  drum  membrane.  In  using  an  ear 
syringe  one  must  always  employ  extreme  gentleness  and  solutions  of 
the  proper  temperature,  otherwise  the  procedure  is  not  only  rendered 
painful,  but  is  capable  of  causing  harm.     Especially  is  it  necessary 


Fig.  383. — Allport's  ear  syringe. 

to  avoid  forcible  injections  in  cases  where  the  tympanum  is  exposed 
through  destruction  of  a  considerable  portion  of  the  drum  membrane. 
The  Syringe. — The  syringe  should  be  simple  in  construction  and 
of  such  material  that  it  may  be  easily  sterilized,  and  should  have  a 
capacity  of  i  or  2  ounces  (30  to  60  c.c).  It  should  be  provided  with 
a  blunt  conical  nozzle — the  ordinary  olive-shaped  tip  is  not  to  be 
commended,  as  it  interferes  with  a  free  return  flow.     A  syringe  with 


Fig.  384. — Metal  ear  syringe  with  a  small  nozzle. 

a  long-pointed  nozzle,  such  as  is  shown  in  Fig.  384,  will  often  be  found 
more  efficacious  in  removing  foreign  bodies  than  the  ordinary 
syringe. 

For  irrigating  the  internal  ear  through  a  perforation  in  the  attic, 
a  smaller  syringe,  such  as  Blake's  (Fig.  385),  with  a  capacity  of  1/2 
dram  (2  c.c),  provided  with  specially  bent  tips,  is  used.  There  will 
be  required,  in  addition,  suitable  illumination,  aural  specula,  and  an 
aural  applicator. 


372  THE   EAR 

Asepsis. — The  syringe  and  nozzle  as  well  as  the  specula  and 
applicator  should  be  sterilized  by  boiling  before  being  used,  and  the 
solution  used  should  be  sterile. 

Solutions  Used. — Normal  salt  solution  (oi  (4  gm.)  of  salt  to  a 
pint  (500  c.c.)  of  boiled  water),  a  saturated  solution  of  boric  acid, 
a  solution  of  bichlorid  of  mercury,  i  to  5000  to  i  to  2000,  are  among 
those  frequently  employed. 

Temperature. — The  solution  should  be  injected  warm — at  about 
a  temperature  of  100°  F.  (t,8°  C).  Cold  solution  should  never  be 
used,  as  it  is  apt  to  cause, vertigo  or  fainting. 

Quantity. — For  the  purpose  of  removing  foreign  bodies  or  wax, 
I  or  2  syringefuls  of  solution  are  usually  sufficient.  When  syringing 
is  employed  in  cases  of  otorrhea,  much  larger  quantities  are  neces- 
sary, as  much  as  1/4  to  i  pint  (125  to  500  c.c.)  being  required  at  a 
time. 

Frequency. — This  will  depend  upon  the  virulence  of  the  infection 


Fig.  385. — Blake's  tympanic  .syringe. 

and  the  amount  of  discharge.  When  the  latter  is  very  profuse, 
syringing  may  be  indicated  three  or  four  times  a  day  or  oftener. 

Position  of  Patient. — The  patient  is  seated  with  the  head  held 
erect. 

Technic. — The  patient's  clothing  is  protected  by  means  of  a  towel 
secured  about  the  neck  and  by  having  him  hold  a  small  glass  basin 
below  the  auricle  to  receive  the  returning  fluid.  The  operator  then 
grasps  the  auricle  between  the  left  thumb  and  forefinger  and  draws  it 
upward  and  backward,  so  as  to  straighten  out  the  external  auditory 
canal.  With  the  right  hand  he  then  introduces  the  nozzle  of  the 
syringe  into  the  external  canal  in  such  a  way  that  the  tip  of  the 
syringe  rests  against  the  superior  wall  of  the  canal,  so  that  the  solu- 
tion, as  it  is  injected,  will  pass  along  the  upper  wall  and  wash. out 
purulent  matter  or  foreign  material  below  (Fig.  386).  The  solution 
is  then  injected  with  only  a  small  amount  of  force  in  sufficient  quanti- 


INSTILLATIONS  373 

ties  for  the  purpose  of  the  operation.  Should  dizziness  or  syncope 
supervene,  the  operation  should  be  immediately  stopped. 

At  the  completion  of  the  syringing  all  moisture  is  removed  by 
means  of  a  cotton-tipped  probe  and,  in  the  presence  of  a  discharge,  a 
strip  of  sterile  gauze  is  lightly  placed  in  the  external  canal. 

In  cases  where  it  is  necessary  to  cleanse  out  the  attic  through 
a  perforation,  the  drum  is  exposed  by  the  aid  of  a  speculum  and 
good  illumination,  and  Blake's  angular  cannula  is  inserted  through 


Fig.  386. — Washing  impacted  cerumen  from  canal.     Showing  how  to  hold  auricle 
to  straighten  the  canal  and  where  to  direct  the  stream  of  water.      (Gleason.) 

the  perforation  under  direct  vision.     The  cavity  is  then  carefully 
cleansed  by  gentle  syringing. 

INSTILLATIONS 

In  some  cases  of  otorrhea  where  the  discharge  has  become  scanty, 
the  long  continued  use  of  douches  often  seems  to  keep  up  an  irritation 
and  a  persistence  of  the  discharge.  In  these  cases  the  instillation  of 
astringent  solutions  for  the  purpose  of  promoting  healthy  granula- 
tions may  be  substituted.  The  solutions  may  be  thus  applied  to  the 
external  auditory  canal  to  affect  the  lining  of  the  canal  or  membrana 
tympani  or  to  the  tympanic  cavity  through  a  perforation  when  the 
latter  contains  unhealthy  granulation  tissue. 

Instruments. — To  instil  a  solution  into  the  external  auditory 
canal,  an  ordinary  glass  medicine  dropper  may  be  employed.     For 


374 


THE    EAR 


tympanic  instillations  a  pipette  glass  dropper  with  a  small  curved 
tip,  a  head  mirror  and  illumination,  and  an  aural  speculum  will 
be  required  (Fig.  387). 


Fig.  387. — Instruments    for    tympanic  instillation.        i,  Head     mirror;    2,    aural 
specula;  3,  glass  instillator. 


use. 


Asepsis. — The  instruments  should  always  be  sterilized  before 
Solutions. — Solutions  of  silver  nitrate  5  to  20  per  cent.,  copper 


Fig.  388. — vShowing  nozzle  of  a  pipette  inserted  for  a  tympanic  instillation. 

sulphate  5  per  cent.,  zinc  sulphate  5  per  cent.,  alcohol  25  to  95  per 
cent,  may  be  used. 

Temperature. — The  solutions  should  always  be  warm — at  about 
100°  F.  (38°  C). 


APPLICATION    OF    CAUSTICS 


375 


Position  of  Patient. — The  patient  should  be  seated  with  the  head 
bent  sideways  so  that  the  affected  ear  hes  uppermost. 

Technic. — The  ear  is  first  cleansed  and  all  secretion  or  fluid  re- 
moved by  means  of  a  cotton-tipped  probe.  The  operator  then 
straightens  out-  the  external  auditory  canal  by  grasping  the  auricle 
between  the  thumb  and  forefinger  of  the  left  hand  and  exerting  trac- 
tion in  an  upward  and  backward  direction.  With  the  right  hand  he 
then  instils  5  to  10  drops  (0.3  to  0.6  c.c.)  of  the  desired  solution  into 
the  auditory  canal.  This  is  retained  for  from  five  to  ten  minutes,  or 
for  a  shorter  time  if  it  causes  burning  or  pain,  and  is  then  permitted 
to  escape  by  having  the  patient  incline  the  ear  downward. 

In  making  intratympanic  instillations  the  auditory  canal  is  first 
cleansed  and  the  drum  is  exposed  by  means  of  a  speculum.  The 
point  of  the  pipette  is  then  carefully  inserted  through  the  perforation 
and  a  few  drops  of  weak  solution  are  injected  (Fig.  388). 


APPLICATION  OF  CAUSTICS 

The  application  of  chemical  caustics  to  the  ear  may  be  required 
for  the  purpose  of  destroying  granulations  or  small  polypi.     The  most 


Fig.  389. — Instruments  for  applying  caustics  to  the  ear.      i,  Head 
aural  specula;  3,  aural  probe;  4,  applicator. 


mirror;   2, 


frequently  employed  agents  for  this  purpose  are  chromic  acid  or 
silver  nitrate.  They  are  applied  fused  upon  the  tip  of  a  deHcate  ear 
probe.  In  making  such  appHcations  with  strong  chemicals  great 
care  must  be  taken  that  the  caustic  only  comes  in  contact  with  the 


376  THE   EAR 

area  to  be  treated.  They  should,  therefore,  only  be  applied  by  the  aid 
of  a  speculum  and  good  illumination. 

Instruments. — There  will  be  required  a  head  mirror  and  a  source 
of  strong  light,  aural  specula,  a  delicate  aural  probe,  and  an  aural 
applicator  (Fig.  389). 

The  method  by  which  the  acid  or  silver  nitrate  is  fused  upon  the 
probe  has  been  previously  described  (see  page  334). 

Asepsis. — The  instruments  should  be  boiled  before  use. 

Position  of  the  Patient. — The  patient  and  the  operator  are  seated 
in  the  same  relative  positions  as  for  an  ordinary  otoscopic 
examination. 

Technic. — With  the  speculum  inserted  in  the  ear  and  the  parts 
well  illuminated,  the  site  of  the  intended  application  is  cleansed  and 
then  thoroughly  dried  by  means  of  cotton  wrapped  upon  the  end  of 
an  aural  applicator.  This  is  very  important,  for  if  any  fluid  be  in  the 
ear  the  caustic  will  spread  to  other  parts  as  soon  as  it  is  applied.  The 
caustic  is  then  carefully  applied  to  the  area  it  is  desired  to  destroy. 

INFLATION  OF  THE  MIDDLE  EAR 

The  value  of  inflation  in  diagnosis  has  been  previously  considered 
(see  page  363).  As  a  therapeutic  measure  it  is  employed  in  tubal  and 
middle-ear  disease  with  occlusion  of  the  tube  for  the  purpose  of  re- 
storing the  normal  tension  between  the  drum  membrane,  ossicles, 
and  the  internal  ear.  The  circulation  is  thus  improved  and  hyper- 
emia and  infiltration  of  the  tubal  and  tympanic  mucous  membrane  is 
diminished.  At  the  same  time  morbid  secretions  are  removed  from 
the  Eustachian  tube  and  tympanic  cavity,  and  newly  formed  ad- 
hesions are  broken  down. 

The  methods  by  which  inflation  may  be  performed  and  the  technic 
will  be  found  described  on  page  364. 

INFLATION  WITH  MEDICATED  VAPORS 

In  certain  cases  of  subacute  or  chronic  nonsuppurative  otitis 
media,  inflation  with  medicated  vapors  is  often  employed  to  better 
advantage  than  plain  air.  The  vapor  of  drugs  having  either  a  seda- 
tive or  stimulating  action  may  be  used.  In  this  way  all  the  benefits 
of  inflation  plus  the  sedative  or  stimulating  effect  of  the  vapor  upon 
the  mucous  membrane  are  obtained. 

Apparatus. — A  vaporizer,  in  which  the  air  current  passes  over  the 
volatile  drug  it  is  desired  to  employ,  attached  to  an  Eustachian  cath- 


INJECTION    OF    SOLUTIONS    INTO    EUSTACHIAN    THE    TUBES       377 

eter,  forms  the  necessary  apparatus.  There  are  a  number  of  con- 
venient vaporizers,  such  as  Hartmann's,  Pynchon's,  or  Dench's 
(Fig.  390).  The  latter  apparatus  is  especially  useful,  as  plain  air 
or  medicated  vapor  may  be  obtained  by  simply  turning  a  key  on  the 
top  of  the  bottle. 

Asepsis. — The  catheter  should  be  sterilized  by  boiling  before  use. 

Formulary. — Vapors  of  menthol,  camphor,  eucalyptol,  iodin, 
turpentine,  chloroform,  and  ether  alone  or  in  combination  are  most 
frequently  employed. 

Preparation  of  Patient. — Same  as  for  catheterization  (see  page 

364). 

Position  of  Patient. — Same  as  for  catheterization  (see  page  364). 
Technic. — The  Eustachian   catheter   is   passed   by   one   of   the 


Pig.  390. — Dench's  vaporizer  and  Eutachian  catheter. 

methods  described  on  pages  367  and  370  and  with  all  the  precautions 
detailed  therein.  Inflation  with  air  is  then  performed  in  order  to 
first  force  out  from  the  tube  any  collection  of  mucus  or  secretion  and 
thus  permit  the  medicated  vapor  to  come  in  contact  with  the  mucous 
membrane.  The  medicated  vapor  is  then  blown  into  the  tympanic 
cavity  in  the  same  manner,  after  attaching  the  vaporizer  to  the 
catheter. 

THE  INJECTION   OF  SOLUTIONS  INTO    THE  EUSTACHIAN 

TUBES 

Direct  medication  of  the  Eustachian  tubes  may  be  used  to  advan- 
tage in  the  treatment  of  middle-ear  catarrh  for  the  purpose  of  lessen- 
ing the  swelling  of  the  mucous  membrane,  and  to  diminish  secretions, 
thereby  rendering  the  tubes  more  permeable.  Weak  astringent 
solutions  are  generally  employed  for  this  purpose,  injected  through  an 
Eustachian  catheter. 


378 


THE    EAR 


Apparatus. — There  will  be  required  an  Eustachian  catheter,  a 
small  syringe,  graduated  in  drops,  and  provided  with  a  tip  that  will 
fit  into  the  proximal  end  of  the  catheter  (Fig.  391),  and  a  Politzer 
air-bag. 

Asepsis. — The  catheter  and  syringe  should  be  boiled,  and  the 
solution  employed  should  be  a  sterile  one. 

Solutions  Used. — lodid  of  potassium  5  gr.  (0.32  gm.)  to  the 
ounce  (30  c.c),  silver  nitrate  2  to  5  gr.  (0.13  to  0.32  gm.)  to  the  ounce 
(30  c.c),  sulphate  of  zinc  i  gr.  (0.065  S^i-)  to  the  ounce  (30  c.c), 
protargol  10  to  50  per  cent.,  bicarbonate  of  soda  2  to  5  gr.  (0.13  to 
0.32  gm.)  to  the  ounce  (30  c.c),  etc.,  may  be  employed. 

Quantity. — About  five  to  ten  drops  (0.3  to  0.6  c.c)  of  the 
selected  drug  are  injected  at  a  time.     If  perforation  of  the  drum 


Fig.  391. — Eustachian  catheter  and  sj^ringe  for  medication  of  the  Eustachian 

tubes. 

exists  more  solution  may  be  safely  used,  but  in  its  absence  small 
amounts  only  are  applicable. 

Preparation  of  the  Patient. — Same  as  for  catheterization  (see 
page  364). 

Position  of  Patient. — Same  as  for  catheterization  (see  page  364). 

Technic. — The  catheter  is  introduced  into  the  tube  by  one  of  the 
methods  described  on  pages  367  and  370  and  the  ear  is  inflated  by  the 
Politzer  bag  to  empty  it  of  secretion.  The  small  syringe  is  then 
charged  with  the  warmed  solution,  and  the  desired  amount  is  slowly 
injected  through  the  catheter.  The  air-bag  is  then  substituted  for 
the  syringe  and  the  solution  is  blown  into  the  tube. 


THE  EUSTACHIAN  BOUGIE 

Eustachian  bougies  are  employed  in  overcoming  tubal  obstruc- 
tions which  will  not  yield  to  inflation  and  for  the  purpose  of  dilating 
tubal  strictures.  In  the  latter  condition,  however,  the  use  of  the 
Eustachian  bougie  is  rarely  curative  if  the  stricture  is  composed  of 
dense  connective  tissue. 


THE    EUSTACHIAN   BOUGIE  379 

The  bougie  is  passed  into  the  tube  through  a  catheter,  and  it 
should  always  be  inserted  with  the  greatest  care  and  gentleness,  as 
it  is  a  very  easy  matter  to  injure  the  mucous  membrane  with  the  result 
that,  if  inflation  be  immediately  performed,  air  may  be  forced  under 
the  mucous  membrane  through  the  tear  and  cause  emphysema.  It 
is,  therefore,  advisable  to  wait  a  day  or  two  after  passing  the  bougie 
before  inflation  is  attempted.  Care  must  also  be  observed  not  to 
pass  the  bougie  a  greater  distance  than  the  length  of  the  tube;  that 
is,  not  more  than  i  1/4  inches  (3  cm.)  beyond  the  tip  of  the  catheter. 


Fig.    392. — Instruments  for  dilatation  of  the  Eustachian  tubes,      i,  Eustachian 
catheters;  2,  Eustachian  bougies;  3,  Politzer's  inflation  bag. 

Instruments. — There  will  be  required  an  Eustachian  catheter, 
Eustachian  bougies,  and  a  Politzer  air-bag  (Fig.  392).  The  bougies 
are  made  of  silkworm  gut  or  whalebone,  with  tips  conical  or  bulbous 
in  shape,  and  varying  in  diameter  from  1/64  to  1/25  inch  (0.4  mm. 
to  I  mm.).  The  catheter  used  to  guide  the  bougie  into  the  tube 
should  be  somewhat  shorter  than  ordinary  with  a  longer  curved  beak. 

Asepsis. — The  catheters  are  sterilized  by  boiling  and  the  bougies 
by  immersion  in  a  saturated  solution  of  boric  acid. 


Fig.  393. — Showing  the  bougie  inserted  in  the  catheter  ready  to  be  passed  into 

the  Eustachian  tube. 

Frequency, — Bougies  should  not  be  inserted  more  frequently 
than  two  or  three  times  a  week  in  order  to  permit  the  reaction  from 
one  insertion  to  subside  before  another  is  attempted. 

Preparations  of  Patient. — Same  as  for  catheterization  (see  page 

364). 

Position  of  Patient. — Same  as  for  catheterization  (seepage  364). 

Technic. — The  bougie  is  lubricated  and  is  introduced  within  the 
catheter  until  the  tip  is  level  with  the  distal  end  of  the  catheter  (Fig. 
393).     The  catheter,  with  the  bougie  in  place,  is  then  introduced 


380  THE   EAR 

into  the  tube  in  the  manner  described  on  page  367.  The  bougie  is 
then  carefully  passed  into  the  tube  for  not  more  than  i  1/4  inches 
(3  cm.)  which  can  be  accomplished  in  a  normal  tube  without  difficulty. 
If  the  bougie  passes  into  the  Eustachian  tube,  the  patient  will  com- 
plain of  some  pain  in  the  ear,  neck,  or  occiput,  whereas,  if  it  doubles 
back  into  the  pharynx,  discomfort  will  be  felt  in  that  region.  When 
resistance  is  encountered,  the  bougie  should  be  pushed  forward 
slowly  and  with  great  caution,  occasionally  rotating  the  bougie; 
forcible  manipulations  must  always  he  avoided  for  fear  of  injuring  the 
mucous  membrane.  Having  successfully  overcome  the  obstruction, 
the  bougie  is  left  in  situ  for  five  to  ten  minutes.  At  the  next  sitting 
a  larger-sized  bougie  is  employed. 

The  Medicated  Bougie, — A  medicated  bougie,  obtained  by  dip- 
ping a  silkworm-gut  bougie  in  some  astringent  solution,  such  as 
silver  nitrate,  before  its  passage,  often  has  more  pronounced  and  more 
prolonged  effect  than  the  plain  bougie  in  overcoming  a  stenosis  due 
to  congestion  or  inflammation  of  the  mucous  membrane.  The 
medicated  bougie  is  introduced  in  the  same  manner  as  an  ordinary 
bougie,  and  should  be  allowed  to  remain  in  place  about  fifteen  to 
twenty  minutes  to  obtain  a  prolonged  action  of  the  astringent. 

MASSAGE  OF  THE  MEMBRANA  TYMPANI 

Massage  of  the  ear-drum  is  performed  by  alternately  rarefying 
and  condensing  the  air  in  the  external  auditory  meatus.  This  produces 
an  increased  mobility  in  the  membrana  tympani  and  ossicles  with 
the  result  that  adhesive  processes  between  the  drum  membrane  and 
inner  wall  of  the  tympanum  are  avoided  or  broken  up  when  formed 
and  likewise  ankylosis  of  the  ossicular  chain  is  prevented.  The 
method,  therefore,  has  greatest  value  in  adhesive  forms  of  middle-ear 
disease;  in  acute  conditions  its  use  is  contraindicated.  In  all  cases 
an  accurate  diagnosis  is  the  first  essential,  otherwise  massage  may 
result  in  harm.  It  should  be  avoided  in  all  cases  of  relaxed  drum  or 
where  portions  of  the  membrane  are  atrophic.  In  the  latter  condition 
the  atrophied  weakened  portion  will  move  under  the  influence  of 
suction  while  the  rest  of  the  drum  will  be  unaffected. 

Apparatus. — The  massage  is  performed  with  the  Siegle  type  of 
instrument  (see  Fig.  371),  by  means  of  which  the  drum  membrane 
may  be  observed  and  the  effect  of  the  manage  noted. 

Asepsis. — The  speculum  portion  of  the  instrument  should  be 
sterile. 


INCISION    OF    THE    MEMBRANA    TYMPANI  38 1 

Duration. — The  massage  may  be  applied  for  one  to  two  minutes 
at  a  sitting. 

Frequency. — Treatments  should  be  given  two  to  three  times  a 
week,  but  only  so  long  as  improvement  in  distance  hearing  takes 
place. 

Technic. — The  otoscope  is  introduced  into  the  ear  in  the  manner 
described  on  page  360,  and  the  air  is  alternately  rarefied  and  con- 
densed by  relaxation  or  compression  of  the  bulb.  The  amount  of 
pressure  used  should  be  regulated  by  noting  the  effect  upon  the  mem- 
brane and  ossicles.  If  the  procedure  causes  pain,  the  pressure 
should  be  promptly  reduced. 

INCISION  OF  THE  MEMBRANA  TYMPANI 

Incision  of  the  drum  membrane  should  always  be  promptly  per- 
formed in  otitis  media  when  the  drum  is  bulging,  for  the  purpose  of 
establishing  drainage  for  the  exudate  and  thereby  preventing  necrosis 
of  the  membrana  tympani  and  tympanic  contents.  It  is  also  indi- 
cated in  acute  cases  in  which,  while  the  membrane  is  not  actually 
bulging,  it  shows  marked  hyperemia  and  infiltration  and  the  patient 
suffers  from  severe  pain  and  exhibits  constitutional  symptoms  of  a 
severe  infection.  Especially  in  infants  is  early  incision  required  under 
such  conditions.  If  incision  is  delayed  until  bulging  occurs,  exten- 
sive destructive  changes  may  have  occurred  and  the  process  may 
rapidly  extend  to  the  mastoid  antrum  or  to  the  cranial  cavity. 
Finally,  early  incision  is  always  indicated  if  in  the  course  of  middle- 
ear  disease  there  are  signs  of  mastoid  involvement  or  of  meningitis. 

The  extent  of  incision  is  of  importance.  Simple  puncture,  or 
paracentesis,  is  to  be  avoided;  instead,  the  incision  should  be  of 
sufficient  size  to  afford  free  drainage  for  the  products  of  suppuration, 
varying  according  to  the  age  of  the  individual,  from  1/4  to  3/8  inch 
(6  to  9  mm.)  in  length. 

Instruments. — There  will  be  required  a  head  mirror  and  source 
of  illumination  or  an  electric  head  light,  aural  specula,  a  sharp 
paracentesis  knife  (straight  or  angular),  and  an  ear  syringe   (Fig. 

394). 

Asepsis. — The  instruments  should  be  sterilized  by  boiling,  and 
the  operator's  hands  cleansed  as  thoroughly  as  for  any  operation. 

Preparations  of  Patient. — The  external  auditory  canal  should  be 
thoroughly  cleansed  by  syringing  with  warm  saturated  boracic  acid 
solution  or  with  a  i  to  5000  bichlorid  of  mercury  solution. 


382 


THE    EAR 


Anesthesia. — The  operation  is  quite  painful.  In  children  general 
anesthesia  by  chloroform  is  indicated,  while  in  adults  nitrous  oxid 
gas  or  some  form  of  local  anesthesia  may  be  used.  Local  anesthesia, 
by  means  of  a  solution  of  cocain  applied  to  the  unbroken  mem- 
brane, is  not  satisfactory,  as  the  cocain  is  not  absorbed.  Instead, 
the  following  mixture  may  be  employed: 

T^.     Cocain  hydrochlorate,  gr.  vi  (0.4  gm.) 

Anilin  oil, 
Alcohol,  aa  3i  (4  c.c.) 

A  small  amount  of  this  solution  is  instilled  into  the  external  auditory 
canal  and  is  allowed  to  remain  for  lifteen  minutes.     It  must  be  used 


Fig.  394. — Instruments  for  incising  the  drum  membrane,     i,  Head  mirror;  2, 
aural  specula;  3,  angular  paracentesis  knife;  4,  Allport's  ear  syringe. 

with  great  care  if  a  perforation  be  present,  as  it  will  thus  enter  the 
tympanic  cavity  where  absorption  is  rapid  and  toxic  symptoms  may 
result. 

Technic. — The  drum  is  exposed  by  means  of  a  speculum  under 
good  illumination,  and  the  external  canal  is  thoroughly  dried.  The 
knife  is  then  inserted  through  the  membrane  in  the  postero-inferior 
quadrant,  and  the  posterior  quadrant  of  the  drum  is  incised  in  a 
curve  upward  to  the  tympanic  vault  (Fig.  395).  In  doing  this,  the 
knife  should  only  be  inserted  through  the  drum  membrane,  so  as  to 
avoid  injuring  the  inner  tympanic  wall  which  lies  distant  1/12 
to  1/6  inch  (2  to  4  mm.).     Of  course,  if  there  is  any  localized  bulg- 


INCISION    OF    THE    MEilBRANA    TYMPANI 


383 


Fig.  395. — Incision  of  the  membrana  tympani  in  acute  otitis  media  involving  the 
lower  portion  of  the  tympanic  cavitj*.      (Dench.j 


Fig.  396. — Incision  of  the  membrana  tA^mpani  in  acute  otitis  media,  involving  the 
upper  portion  of  the  tympanic  cavitj'.     (Dench.) 


384  THE   EAR 

ing,  the  incision  should  be  so  placed  as  to  relieve  it.  When  the  tym- 
panic vault  alone  is  involved,  the  knife  is  entered  in  the  posterior 
quadrant  opposite  the  short  process  of  the  malleus  and  the  incision 
is  carried  upward  through  Shrapnell's  membrane.  The  knife  is  then 
turned  backward,  and,  as  it  is  wTithdrawn,  the  tissues  of  the  posterior 
wall  of  the  auditory  canal  are  incised  down  to  the  bone  for  a  distance 
of  about  1/8  inch  (3  mm.)  from  the  drum  (Fig.  396).  In  this  way 
tension  in  the  tympanic  vault  and  mastoid  is  relieved. 

The  ear  is  then  carefully  cleansed  by  syringing  and,  after  being 
well  dried,  is  loosely  packed  with  gauze. 

After-treatment. — The  ear  should  be  syringed  with  a  warm  i  to 
5000  bichlorid  of  merciiry  solution  as  often  as  secretion  collects.  At 
first,  this  will  necessitate  syringing  every  two  or  three  hours.  As  the 
discharge  decreases,  longer  intervals  may  elapse. 


CHAPTER  XV 
THE  LARYNX  AND  TRACHEA 

Anatomic  Considerations 

The  larynx  is  that  portion  of  the  upper  air  passages  extending 
between  the  base  of  the  tongue  and  the  trachea.  It  lies  in  the  median 
line  of  the  neck,  opposite  the  fourth,  fifth,  and  sixth  cervical  verte- 
brae. Anteriorly,  it  is  practically  subcutaneous;  posteriorly,  it 
forms  part  of  the  anterior  boundary  of  the  pharynx;  while  on  either 
side  of  it  lie  the  great  vessels  of  the  neck.  Above,  it  is  broad  and 
triangular  in  shape,  while  below  it  is  narrow  and  cylindrical. 

The  framework,  consisting  of  a  number  of  cartilages  held  together 
by  ligaments,  is  lined  with  mucous  membrane,  and  is  capable  of 
being  moved  by  muscles  which  change  the  relative  positions  of  the 
cartilages  and  thus  modify  the  approximation  of  the  vocal  cords 
during  respiration  and  phonation.  The  most  important  of  these 
cartilages  are  the  thyroid,  the  epiglottis,  the  cricoid,  and  the  two 
arytenoids. 

The  thyroid  cartilage  is  the  largest  of  all,  and  consists  of  two 
broad  lateral  alas  joined  in  front  at  an  acute  angle.  Above,  it  is 
joined  to  the  hyoid  bone  by  the  thyrohyoid  membrane,  and,  below,  to 
the  cricoid  cartilage  by  the  cricothyroid  membrane.  The  space 
between  the  thyroid  and  cricoid  cartilages  in  an  adult  measures 
about  half  an  inch  (i  cm.)  in  height;  an  opening  made  through  this 
space  gives  easy  access  to  the  larynx  below  the  vocal  cords. 

The  epiglottis  is  a  leaf-shaped  piece  of  elastic  cartilage  i  1/3  inches 
(3.5  cm.)  long,  guarding  the  superior  entrance  of  the  larynx.  It  is 
attached  by  its  stalk  to  the  upper  and  posterior  aspect  of  the  angle 
between  the  thyroid  alae  and  to  the  hyoid  bone  by  ligaments.  It 
lies  directly  behind  the  tongue,  and  in  swallowing  it  is  pushed  back- 
ward by  the  bolus  of  food,  closing  more  or  less  completely  the  laryn- 
geal opening  and  thereby  preventing  the  entrance  of  food  into  the 
larynx. 

The  cricoid    cartilage  is  a    small,   nearly  semicircular   cartilage 
forming  the  lower  part  of  the  cavity  of  the  larynx.     It  is  narrow  in 
front,  but  becomes  broadened  and  high  posteriorly.     Upon  its  supe- 
rior border  on  either  side  it  supports  the  arytenoid  cartilages. 
25  385 


386 


THE    LARYNX   AND    TRACHEA 


The  arytenoid  cartilages,  two  in  number,  are  irregularly  pyram- 
idal in  shape  and  rest  by  their  bases  on  the  superior  border  of  the 
cricoid  cartilage.  They  rotate  upon  a  vertical  axis  and  also  move 
laterally.  Through  these  movements  the  vocal  cords  are  approxi- 
mated or  drawn  apart. 

The  Interior  of  the  Larynx. — The  superior  opening  is  wide  and 
semicircular  in  front  where  it  is  bounded  by  the  epiglottis.  The 
sides  are  formed  by  the  arytenoepiglottic  folds  of  mucous  membrane 
which  run  from  the  sides  of  the  epiglottis  to  the  tops  of  the  arytenoid 
cartilages  and  gradually  approach  posteriorly,  so  that  the  opening  is 


Fig.  397. — Anterior  view  of  the  larynx.  (After  Deaver.)  i,  Epiglottis;  2, 
lesser  cornu  of  hyoid  bone;  3,  greater  cornu  of  hyoid  bone;  4,  thyrohyoid  mem- 
brane; 5,  thyroid  cartilage;  6,  cricothyroid  membrane;  7,  cricoid  cartilage;  8, 
trachea. 


narrowed  behind.  More  or  less  distinct  nodular  prominences 
formed  by  the  cuneiform  and  corniculate  cartilages  are  recognized 
on  these  folds. 

The  cavity  of  the  larynx  extends  from  the  superior  aperture  to 
the  lower  border  of  the  cricoid  cartilage.  It  is  divided  into  two  por- 
tions by  the  vocal  cords — above,  into  the  supraglottic  region,  and, 
below,  into  the  subglottic  region.  The  vocal  cords  consist  of  two 
delicate  bands  of  elastic  tissue  enclosed  in  thin  layers  of  mucous  mem- 
brane having  a  whitish  appearance.  They  are  attached  anteriorly 
to  the  thyroid  cartilage  and  posteriorly  to  the  arytenoids.  They 
measure  about  3/4  inch  (2  cm.)  in  length  in  the  male,  and  1/2  inch 
(i  cm.)  in  the  female.     Between  the  two  cords  is  a  long  narrow 


ANATOMIC    CONSIDERATIONS 


387 


chink,  the  glottis.  Above  and  parallel  to  the  vocal  cords  are  two 
second  folds  of  mucous  membrane  enclosing  ligamentous  tissue,. 
attached  to  the  thyroid  cartilage  in  front  and  to  the  two  arytenoids 
behind,  commonly  called  the  false  vocal  cords.  Lying  between  the 
vocal  cords  and  these  two  bands  are  two  oblong  fossae,  the  ventricles 
of  the  larynx. 

The  mucous  membrane  of  the  larynx  is  continuous  above  with 
that  lining  the  pharynx,  and  below  with  that  of  the  trachea  and  bron- 
chi. It  is  of  the  columnar  ciliated  variety,  excepting  where  it  covers 
the  vocal  cords  and  the  space  above  the  vocal  cords,  in  which  regions 
it  is  of  the  stratified  variety.  It  contains  many  mucous  glands,  espe- 
cially numerous  upon  the  epiglottis. 


Fig.  398. — The  interior  of  the  larynx,  i,  Epiglottis;  2,  thyroid  cartilage;  3, 
ventricle  of  larynx;  4,  cricoid  cartilage;  5,  false  vocal  cords;  6,  vocal  cords;  7, 
first  ring  of  trachea. 

The  trachea  is  a  cylindrical  tube,  composed  of  cartilages  and 
membrane,  extending  from  the  cricoid  cartilage,  at  the  level  of  the 
sixth  cervical  vertebra,  to  a  point  opposite  the  fourth  dorsal,  where  it 
divides  into  a  right  and  left  bronchus.  It  is  from  4  to  4  3/4  inches 
(10  to  12  cm.)  long  in  males,  and  from  3  2/3  to  4  1/2  inches  (9  to  11 
cm.)  long  in  females.  Its  transverse  diameter  measures  on  an 
average  4/5  of  an  inch  (2  cm.)  in  males,  and  less  in  females.  In  a 
child  of  from  two  to  four  years,  the  transverse  diameter  measures 
1/3  of  an  inch  (8  mm.) ;  in  a  child  under  eighteen  months,  it  measures 
1/4  of  an  inch  (6  mm.). 

The  framework  of  the  trachea  is  composed  of  from  sixteen  to 


388 


THE    LARYNX   AND    TRACHEA 


nineteen  rings  of  hyaline  cartilage,  incomplete  behind,  each  measur- 
ing 1/12  to  1/5  of  an  inch  (2  to  5  mm.)  in  breadth.  The  narrow 
space  between  these  rings  is  filled  with  an  elastic  fibrous  membrane 
which  splits  into  two  layers  to  enclose  each  cartilage,  and  also 
serves  to  complete  the  tube  posteriorly.  Internally,  the  trachea  is 
lined  with  a  smooth  mucous  membrane  of  the  ciliated  variety,  con- 
tinuous above  with  that  of  the  larynx  and  below  with  that  of  the 
bronchi.  It  contains  an  abundance  of  lymphoid  tissue  and  mucous 
glands.  ♦ 


"ThyfoicL 


J7r/'co-/Ayr'. 
Tncmbrane 


Inf.  thyr.  art. 

iXi'yfif' Comnte>v^  ^^^         '    '^^^  ij-'S^  — " 

Canft/datK 


crr/e/y 


/.eft  Jube/avian, 


Fig.  399. — Anatomy  of  the  trachea  and  its  relations. 

The  trachea  lies  in  a  mass  of  loose  fat  which  permits  free  motion 
upward,  downward,  and  horizontally.  In  its  upper  part  it  lies  com- 
paratively superficial,  but  becomes  more  deeply  placed  as  it  ap- 
proaches the  thorax.  The  isthmus  of  the  thyroid  gland  lies  opposite 
the  second  and  third  rings;  below  this  the  following  structures  will 
be  met  from  above  downward:  the  inferior  thyroid  veins,  the  arteria 
thyroidea  ima  (if  present),  the  sternohyoid  and  sternothyroid  mus- 
cles, the  cervical  fascia,  an  anastomosis  of  the  anterior  jugular  veins; 
and  in  the  thorax,  the  remains  of  the  thymus  gland,  the  left  innomi- 


LARYNGOSCOPY  AND  TRACHEOSCOPY  389 

nate  vein,  the  arch  of  the  aorta,  and  the  innominate  and  the  left 
common  carotid  arteries.  Behind  hes  the  esophagus.  Laterally, 
the  trachea  is  in  relation  with  the  common  carotid  arteries,  the 
lateral  lobes  of  the  thyroid,  the  inferior  thyroid  arteries,  and  the  re- 
current laryngeal  nerves.  These  relations  are  important  to  bear  in 
mind  in  performing  tracheotomy. 

Diagnostic  Methods 

The  diagnostic  methods  employed  in  connection  with  the  larynx 
and  trachea  consist  in  (i)  inspection  by  means  of  a  laryngeal  mirror, 
(2)  direct  inspection  through  endoscopic  tubes,  (3)  palpation  by  the 
probe  or  finger,  and  (4)  skiagraphy. 

As  a  preliminary  to  the  actual  local  examination,  attention 
should  first  be  given  to  the  general  condition  of  the  patient,  and  the 
history  of  other  affections  that  may  have  a  bearing  upon  the  condi- 
tion should  be  inquired  into.  This  is  important,  for,  while  the  symp- 
toms of  processes  involving  this  portion  of  the  respiratory  tract  are 
characteristic  (consisting  of  cough,  dyspnea,  aphonia  or  dysphonia, 
dysphagia,  etc.),  and  as  a  rule  clearly  indicate  the  seat  of  the  trouble, 
it  should  be  borne  in  mind  that  many  of  these  symptoms  are  second- 
ary to  other  conditions,  such  as  gout,  diphtheria,  rheumatism, 
diabetes,  nephritis,  tuberculosis,  syphilis,  diseases  of  the  nervous 
system,  etc.  Thus  it  becomes  of  the  utmost  importance  to  examine 
other  organs  as  well  and  not  to  hmit  the  investigation  to  the  affected 
region  alone. 

Having  completed  this  portion  of  the  examination,  external  in- 
spection and  palpation  of  the  parts  should  be  performed.  In  this 
way  the  presence  of  inflammation,  sweUings,  new  growths,  enlarged 
glands,  fractures  of  the  cartilages,  etc.,  may  be  determined,  and  the 
mobility  or  fixation  of  the  parts  during  swallowing  and  respiration 
may  be  noted. 

LARYNGOSCOPY  AND  TRACHEOSCOPY 

By  this  method  the  interior  of  the  larynx  and  trachea  are  in- 
.  spected  by  means  of  a  laryngoscopic  mirror  and  reflected  light.  The 
technic  is  not  diihcult,  and,  if  properly  carried  out,  a  satisfactory  in- 
spection of  the  tissues  may  be  made  as  far  as  the  true  vocal  cords, 
and  under  favorable  conditions  the  region  beyond  the  glottis  as  far 
as  the  subdivision  of  the  trachea  may  also  be  explored,  and  foreign 


390 


THE    LARYNX    AND    TRACHEA 


bodies  or  pathological  conditions  recognized.  Such  examination  is 
best  made  before  a  meal,  as,  otherwise,  retching  and  vomiting  may  be 
induced. 

Instruments  and  Apparatus. — Requisites  for  an  ordinary  laryngo- 
scopic  examination  are:  a  strong  light,  such  as  is  obtained  from 
a  Welsbach  burner  covered  by  a  Mackenzie  condenser;  a  concave  head 
mirror,  3  1/2  to  4  inches  (9  to  10  cm.)  in  diameter  with  a  central 
perforation  for  the  eye;  laryngeal  mirrors  of  three  sizes,  1/2,  i,  and 
I  1/2  inches  (i,  2.5,  and  4  cm.)  in  diameter,  that  they  may  be 
adapted  to  the  size  of  the  individual  fauces;  and  an  alcohol  lamp 
(Fig.  400).     The  light  should  be  placed  upon  a  suitable  bracket, 


Fig.  400. — Instruments  for  laryngoscopy.     I,  Laryngeal  mirrors;  2,  head  mirror; 

3,  alcohol  lamp. 


that  it  may  be  raised  or  lowered  to  any  desired  height  (see  Fig.  310). 

Asepsis. — The  laryngeal  mirrors  should  be  sterilized  by  immersion 
in  a  I  to  20  solution  of  carbolic  acid,  then  rinsed  off  in  sterile  water 
and  dried  before  use. 

Position  of  Patient  and  Examiner. — To  obtain  the  best  results, 
the  examination  should  be  performed  in  a  partially  darkened  room. 
The  patient  sits  in  a  straight-backed  chair  with  the  head  raised  and 
inclined  slightly  backward.  The  light  is  located  upon  the  patient's 
right,  a  little  behind  him  and  about  on  a  level  with  the  ear.  The 
operator  sits  facing  the  patient,  with  his  knees  to  one  or  the  other 
side  of  the  patient's,  and  with  his  eye  on  a  level  with  the  patient's 


LARYNGOSCOPY  AND  TRACHEOSCOPY 


391 


mouth,  at  a  distance  of  about  a  foot  (30  cm.),  or  the  focal  length  of 
the  mirror. 

Anesthesia. — Ordinarily,  cocainization  of  the  parts  is  unneces- 


FiG.  401. — Laryngoscopy.     First   step,    showing   the   method   of   grasping   the 

tongue. 

sary,  but,  where  the  mucous  membrane  of  the  pharynx  is  very  sen- 
sitive, brushing  a  4  per  cent,  solution  of  cocain  over  the  posterior 
pharyngeal  wall  and  soft  palate  may  be  required  before  a  satisfactory 
examination  is  possible. 


Fig.  402. — Laryngoscopy.     Second  step,  heating  the  mirror. 

Technic. — The  operator  places  himself  and  patient  in  the  proper 
positions,  and  adjusts  the  head  mirror  over  the  left  eye  in  such  a 
manner  that  the  light  will  be  reflected  in  a  circle  upon  the  mouth  of 


392 


THE    LARYNX   AND   TRACHEA 


the  patient.  The  patient  is  then  directed  to  protrude  the  tip  of  the 
tongue,  which  is  surrounded  with  a  piece  of  clean  gauze  or  small 
napkin  and  is  grasped  between  the  thumb  and  forefinger  of  the  opera- 
tor's left  hand  (Fig.  401).     Light  traction  is  made  outward  and  sightly 


FiG.  403. — Showing  the  method  of  holding  the  mirror. 

upward  rather  than  downward,  so  as  to  avoid  forcing  the  under  sur- 
face of  the  tongue  against  the  lower  incisor  teeth.  The  laryngeal 
mirror  is  then  warmed  to  avoid  condensation  of  moisture  upon  its 
reflecting  surface,  by  holding  it  at  a  httle  distance  above  a  flame  for  a 


I 
Fig.  404. — Laryngoscopy.     Third  step,   showing  the  mirror  being  introduced 
and  also  the  relative  position  of  the  patient  and  examiner  and  the  position  of  the 
light. 

few  seconds  (Fig.  402),  the  precaution  being  taken  to  test  the  temperature 
of  the  mirror  before  introducing  it  into  the  mouth;  this  is  determined 
by  bringing  the  back  of  the  mirror  in  contact  with  the  back  of  the 
operator's  hand.     To  introduce  the  mirror,  it  should  be  held  lightly 


LARYNGOSCOPY  AXD  TRACHEOSCOPY 


393 


between  the  thumb  and  forefinger  of  the  right  hand  with  its  reflect- 
ing surface  downward  (Fig.  403),  and  should  be  made  to  follow  the 
curve  of  the  hard  palate  until  its  back  touches  the  uvula  and  soft 
palate.  It  is  then  pushed  upward  and  backward,  raising  the  uvula 
as  far  out  of  the  way  as  possible.  Care  must  be  taken  in  performing 
this  maneuver  to  avoid  touching  the  base  of  the  tongue,  and,  when 
the  mirror  is  in  position,  to  keep  it  held  steadily  in  place  so  as  not  to 
excite  gagging  or  retching.  Should  this  accident  occur,  the  mirror 
must  be  removed  and  sufficient  time  must  be  allowed  for  the  patient 
to  recover  his  breath  and  the  irritabiHty  to  subside  before  it  is  rein- 


FiG.  405.— Lan-ngoscopy.     Fourth  step,   showing  the  mirror  in  place. 

(J.  U.  Anders.) 

troduced.  As  soon  as  the  instrument  is  in  proper  position,  the 
handle  is  moved  to  one  side  of  the  patient's  mouth  so  as  to  be  well 
out  of  the  line  of  vision.  The  mirror  is  then  slowly  and  gently  turned 
until  a  view  of  the  base  of  the  tongue  is  obtained,  and  any  abnor- 
malities of  the  organ  are  noted;  it  is  then  rotated  in  such  a  manner 
that  its  face  looks  downward  and  the  larynx  is  brought  into  view 
(Fig.  405). 

It  should  be  remembered  that  the  laryngeal  image  ^dll  be  in- 
verted— that  is,  the  structures  of  the  front  part  of  the  larynx  appear 


394 


THE   LARYNX   AND   TRACHEA 


on  the  upper  part  of  the  mirror,  and  vice  versa;  the  right  and  left 
sides  of  the  laryngeal  image,  of  course,  correspond  to  the  same  sides 
of  the  patient.  In  a  normal  case,  the  following  are  noted:  at  the 
upper  part  of  the  picture,  the  saddle-shaped  epiglottis  of  a  yellowish 
color  traversed  by  its  pink  blood-vessels;  extending  backward  across 


Fig.  406.  Fig.  407. 

Fig.  406. — The  laryngoscopic  image.  I,  Epiglottis;  2,  false  vocal  cords;  3, 
vocal  cords;  4,  glossoepiglottic  fossa;  5,  interarytenoid  space;  6,  cartilage  of  San- 
torini  and  the  location  of  the  arytenoid  cartilage;  7,  cartilage  of  Wrisberg. 

Fig.  407. — The  larynx  during  gentle  respiration. 

the  mirror  back  of  the  epiglottis  are  a  pair  of  pearly-white  bands, 
the  vocal  cords;  parallel  to  the  vocal  cords,  but  lying  anteriorly  and 
outside,  are  a  second  pair  of  bands  with  a  reddish  hue,  the  ventric- 
ular bands,  or  false  vocal  cords;  between  the  vocal  cords  and  the 
ventricular  bands  may  be  observed  the  ventricles  of  the  larynx, 
brought  into  better  view  if  the  head  is  tilted  to  the  side;  where  the 


Fig.  408. — The     larynx    in     phonation. 


Fig.  409. — The    larynx    during    deep 
respiration. 


vocal  cords  terminate  at  the  lower  part  of  the  image  are  to  be  seen 
the  arytenoid  cartilages,  and  between  them  the  interarytenoid  space; 
extending  from  either  side  of  this  notch  to  join  the  epiglottis  are  the 
aryepiglottic  folds,  with  the  two  prominences  marking  the  site  of  the 
cartilages  of  Wrisberg  and  Santorini,  the  latter  lying  on  top  of  the 


LARYNGOSCOPY  AND  TRACHEOSCOPY  395 

arytenoid  cartilages;  on  either  side  of  the  image  will  be  noted  the 
glossoepiglottic  fossee. 

To  make  a  complete  examination,  the  larynx  should  be  inspected 
during  quiet  respiration,  deep  respiration,  and  phonation.  During 
respiration  the  vocal  cords  are  seen  to  move  with  each  expiration 
toward  the  median  line,  and  away  from  the  median  line  with  inspira- 
tion (Fig.  407).  By  requesting  the  patient  to  say  "ee"  or  "he,"  a 
view  is  obtained  of  the  larynx  with  the  cords  almost  in  apposition  and 
the  interarytenoid  space  obhterated  (Fig.  408).  During  deep  respi- 
ration the  cords  are  widely  separated,  and  a  view  is  obtained  of  the 
anterior  wall  of  the  region  below  the  vocal  cords  (Fig.  409).  There 
will  be  seen  the  broad  yellow  cricoid  cartilage  and  the  yellowish  car- 
tilaginous rings  of  the  anterior  wall  of  the  trachea  with  the  interven- 
ing red  membranous  portion.  By  tilting  and  carefully  adjusting  the 
mirror,  the  bifurcation  of  the  trachea  and  the  openings  of  the  two 
bronchi  may  be  brought  into  view.  To  obtain  the  most  favorable 
position  for  inspection  of  the  trachea,  the  patient's  neck  should  be 
held  straight  and  the  chin  extended  somewhat  forward.  The  mirror 
will  also  require  a  different  adjustment,  being  held  more  horizontally 
than  for  laryngoscopy,  and  the  surgeon  should  be  seated  lower. 

The  diseases  that  may  affect  this  portion  of  the  respiratory  tract 
are  not  different  from  what  one  would  find  in  other  regions  com- 
posed of  the  same  tissues.  The  examiner  should  accordingly  first 
note  the  color  of  the  various  parts  brought  to  view  for  signs  of  con- 
gestion or  inflammation,  bearing  in  mind  that  if  cocain  has  been  em- 
ployed the  parts  will  appear  anemic,  and  that  gagging  or  retching 
may  be  responsible  for  congestion.  He  should  look  for  the  presence 
of  exudations,  foreign  bodies,  and  any  structural  changes,  such  as 
ulcerations,  swellings,  abscesses,  edema,  new  growths,  malforma- 
tions, and  dislocations  of  the  arytenoid  cartilages,  etc.  Finally,  the 
condition  and  mobility  of  the  vocal  cords  during  respiration  and 
phonation  are  observed.  They  should  approximate  symmetrically  in 
the  mid-fine  during  phonation,  and  separate  equaUy  with  inspiration. 
The  whole  examination  should  be  made  as  rapidly  as  possible,  not 
more  than  half  a  minute  or  so  being  consumed,  to  avoid  tiring  the 
patient  and  inducing  an  irritable  state  of  the  parts.  Since  often  only 
a  glimpse  of  the  various  structures  may  be  thus  obtained,  it  may  be 
necessary  to  make  more  than  one  inspection  before  the  whole  ex- 
amination is  completed  in  a  satisfactory  manner. 

Difficulties  in  Laryngoscopy. — It  is  sometimes  a  difiScult  matter 
for  a  beginner  to  inspect  the  parts,  owing  to  faulty  technic  or  to 


396  THE  LARYNX  AND  TRACHEA 

structural  peculiarities.  A  view  of  the  larynx  may  be  missed  entirely 
through  an  improper  adjustment  of  the  light,  faulty  position  of  the 
patient's  head,  or  holding  the  mirror  at  a  wrong  angle.  Clumsy 
and  hasty  introduction  of  the  mirror,  the  use  of  a  mirror  too  hot  or 
too  cold,  or  rough  traction  on  the  tongue,  all  militate  against  success. 
In  some  cases  an  excessive  irritability  of  the  pharynx  precludes  a 
successful  examination  without  preliminary  cocainization.  In  other 
cases  the  presence  of  enlarged  tonsils  may  prevent  a  good  view  of  the 
parts.  If  such  a  condition  is  present,  a  small  oval  mirror  should  be 
substituted.  A  large  pendulous  epiglottis  is  not  infrequently  a  cause 
of  difficulty.  By  placing  the  mirror  close  to  the  posterior  pharyn- 
geal wall  and  holding  it  more  nearly  vertical  than  usual,  with  the 
patient's  head  thrown  back,  a  better  view  may  often  be  obtained. 

In  young  children  considerable  difficulty  may  be  encountered. 
It  is  best  to  wrap  the  child  in  a  sheet  so  that  the  arms  are  restrained, 
and  to  have  it  held  upon  the  lap  of  an  assistant,  who  also  steadies 
the  child's  head.  A  tongue  depressor  with  a  curved  tip  should  be 
employed  to  hold  the  tongue  forward,  and,  if  necessary,  a  mouth-gag 
may  be  inserted  between  the  teeth.  A  small  laryngeal  mirror  is 
then  introduced,  and  the  examination  is  mg-de  in  the  usual  way.  If 
carefully  and  gently  performed,  a  satisfactory  examination  may 
often  be  made  even  upon  unruly  children. 

DIRECT  LARYNGOSCOPY 

The  larynx  and  portions  of  the  air  passages  beyond  may  be  exam- 
ined under  direct  vision  either  by  the  aid  of  illuminated  tubes  or  by 
means  of  a  suitable  tongue  depressor  and  illumination  from  a  head 
light,  the  latter  a  method  designated  by  Kirstein  as  autoscopy.  The 
parts  inspected  in  this  manner  appear  more  nearly  normal  as  to  posi- 
tion and  color  than  when  a  laryngeal  mirror  is  employed.  Further- 
more, foreign  bodies  and  new  growths  may  be  removed,  and  applica- 
tions made  to  diseased  areas  under  direct  vision.  The  method  may 
be  employed  in  young  children  upon  whom  ordinary  laryngoscopy  is 
difficult,  and  it  may  also  be  performed  upon  a  patient  under  general 
anesthesia.  It  is,  however,  more  uncomfortable  for  the  conscious 
patient  than  ordinar}'  laryngoscopy. 

Instruments. — A  tubular  spatula,  self-illuminated,  such  as  Jack- 
son's (Fig.  410),  or  with  the  illumination  furnished  from  an  electric 
head  light,  as  Killian's,  is  generally  employed.  Kirstein  uses  a 
tongue  depressor  of  special  shape  (Fig.  411)  and  an  electric  head 


DIRECT    LARYNGOSCOPY 


397 


light  (Fig.  412).    In  addition  a  mouth-gag  and  a  Sajous  applicator 
are  required  (Fig.  413). 


Fig.  410. — Jackson's  self-illuminated  tube  spatula  for  direct  laryngoscopy. 

Asepsis, — The  tubes  and  tongue  depressor  may  be  boiled,  while 
the  light-carrying  apparatus  in  the  self-illuminated  tube  is  sterilized 
by  immersion  in  alcohol. 

Position  of  the  Patient. — The  patient  is  seated  on  a  low  stool  with 
the  upper  part  of  the  body  bent  slightly  forward  and  with  the  head 
raised  and  thrown  back  so  that  a  direct  view  from  above  downward 


Fig.  411. — Kirstein's  tongue  depressor. 

is  possible.  An  assistant  stands  or  sits  behind,  supporting  the 
patient's  head,  and  holding  the  mouth-gag  in  proper  position.  The 
operator  stands  in  front. 

A  child  should  be  seated  upon  the  lap  of  a  nurse,  who  encircles 
its  body  with  her  arms,  confining  the  child's  arms  closely  to  its  sides 
and  clasping  its  legs  between  her  knees.     The  child's  head  rests  upon 


398 


THE    LARYNX    AND    TRACHEA 


the  nurse's  shoulder,  being  held  in  the  proper  position  from  behind 
by  an  assistant. 

Anesthesia.— Cocainization  of  the  parts  is  usually  necessary  to 
avoid  unpleasant  gagging  and  retching.  This  is  accomphshed  by 
tlie  application  to  the  larynx  and  neighboring  parts  of  a  4  per  cent, 
solution  of  cocain  by  means  of  a  cotton  swab  held  by  a  Sajous  appli- 
cator.    This  should  be  performed  by  the  aid  of  a  laryngeal  mirror. 


Fig.  412. — Kirstein's  head  light. 

If  operative  procedures  are  required,  the  application  of  20  per  cent, 
solution  of  cocain  should  follow  the  preHminary  cocainization.  In 
young  children  the  examination  may  be  carried  out  under  general 
anesthesia. 

Technic. — The  operation  should,  when  possible,  be  performed 
when  the  stomach  is  empty,  as,  otherwise,  retching  may  result  in 
regurgitation  of  the  stomach  contents.     The  parts  having  been  cocain- 


FiG.  413. — Sajous'  applicator  and  mouth-gag. 

ized,  and  with  the  patient  seated  in  the  proper  position,  a  mouth-gag 
is  inserted  in  one  side  of  the  mouth  and  is  held  in  place  by  the 
assistant  who  supports  the  head.  With  the  lamp  at  the  end  of  the 
instrument  properly  lighted,  if  a  self-illuminated  spatula  is  employed, 
or  with  the  head  lamp  lit  and  adjusted  so  as  to  throw  the  light  into 
the  mouth,  if  a  nonilluminated  tube  is  used,  the  tubular  speculum  is 


DIRECT    LARYNGOSCOPY 


399 


introduced  past  the  base  of  the  tongue  until  the  epiglottis  appears. 
Its  tip  is  passed  to  a  point  about  1/2  inch  (i  cm.)  below  the  free  edge 
of  the  epiglottis,  which  is  then  drawn  forward,  and  with  it  the  base 
of  the  tongue  out  of  the  line  of  vision  by  exerting  pressure  upon  the 
handle  of  the  instrument  in  an  upward  and  backward  direction 
(Fig.  414). 

The  operator  then  inspects  the  larynx  by  looking  down  the  tube. 
The  arytenoid  cartilages,  vocal  cords,  interior  of  the  larynx,  and  por- 
tions of  the  trachea  may  thus  be  viewed  in  detail.  The  points  espe- 
cially to  be  noted  in  such  examination  have  already  been  referred  to 


piG.  414. — Direct  laryngoscopy  with  Jackson's  self-illuminated  spatula.  (Modi- 
fied from  Ballenger,)  a.  Electric  cord  supplying  lamp  of  speculum;  b,  conduit  for 
light  carrying  tube;  c,  shows  the  tube  holding  the  epiglottis  forward;  d,  conduit 
for  removing  secretions,  etc.,  by  aspiration  during  the  examination. 


under  laryngoscopy.  By  the  aid  of  these  tubes,  applications  may 
also  be  made,  if  desired,  to  diseased  areas,  and  growths  may  be  re- 
moved by  means  of  delicate  instruments  of  special  design. 

Under  the  method  designated  by  Kirstein  as  autoscopy,  the 
patient  is  placed  in  the  same  position  as  above,  the  mouth  is  illumi- 
nated from  the  electric  head  light,  and  the  special  tongue  depressor 
is  gently  introduced  behind  the  tongue  until  its  tip  rests  between  the 
epiglottis  and  the  base  of  the  tongue.  By  elevating  the  handle  of 
the  instrument,  the  base  of  the  tongue  is  drawn  downward  and  for- 
ward, and  the  epiglottis  is  raised,  so  that  a  groove  is  formed  along 


400  THE  LARYNX  AND  TRACHEA 

the  back  of  the  tongue.  With  the  head  light  properly  adjusted  the 
operator  looks  down  this  groove  and  inspects  the  larynx.  The 
posterior  walls  of  the  larj-nx  and  trachea  are  clearly  viewed  by  this 
method,  but  the  anterior  parts  are  not  seen  so  well  as  with  the 
laryngoscopic  mirror. 

DIRECT  TRACHEO-BRONCHOSCOPY 

In  1897  Killian  devised  long  endoscopic  tubes  that  could  be  intro- 
duced through  the  mouth  or  through  a  tracheotomy  wound,  with 
which  the  trachea  and  bronchi  may  be  examined  by  the  aid  of  illu- 
mination from  an  electric  head  light.  This  operation  is  designated 
respectively  as  "upper  direct  tracheo-bronchoscopy,"  and  "lower 
direct  tracheo-bronchoscopy."  In  this  country,  Chevalier  Jackson 
has  perfected  similar  tubes,  in  which,  however,  the  illumination  is 
suppHed  by  a  small  electric  light  at  the  distal  end  of  the  instrument. 

The  bronchoscope  is  employed  both  for  diagnostic  and  ther- 
apeutic purposes,  and  is  of  especial  value  in  locating  and  removing 


Fig.  415 — Killian''.i  bronchoscope. 

foreign  bodies  and  growths  from  the  air  passages,  or  in  making  direct 
applications  to  ulcers  and  other  lesions  in  the  trachea  and  bronchi. 
Marvelous  results  have  been  obtained  by  those  expert  in  the  use  of 
these  instruments,  and  foreign  bodies  have  been  frequently  removed 
from  the  bronchi  of  patients  upon  whom  thoracotomy  would  other- 
wise have  been  required.  The  use  of  the  bronchoscope,  however, 
requires  such  skill  and  practice  as  to  be  only  of  service  in  the  hands 
of  an  accomplished  specialist;  in  unskilled  hands  it  becomes  a  danger- 
ous instrument. 

Tracheo-bronchoscopy  through  a  tracheotomy  wound  is  the 
simpler  of  the  two  methods,  and,  as  larger  tabes  may  be  employed 
than  in  the  upper  operation,  it  is  often  of  value  for  the  removal  of 
foreign  bodies  too  large  to  be  extracted  by  upper  tracheo-bronchos- 
copy. Upper  tracheo-bronchoscopy,  however,  should  be  the  opera- 
tion of  choice  when  possible. 


DIRECT    TRACHEO-BRONCHOSCOPY 


401 


Instruments. — The  tubes  employed  are  of  rigid,  metal  highly 
polished  internally,  somewhat  similar  to  the  endoscopic  tubes  em- 
ployed in  the  urethra.  They  vary  in  size  according  to  the  age  of 
the  patient  and  the  part  of  the  air  passages  to  be  explored.  Only 
the  smallest  sized  tubes  should  be  used  for  the  bronchi.  Jackson 
employes  for  lower  tracheo-bronchoscopy  a  tube  1/3  inch  (8  mm.)  in 


Fig.  416 — Jackson's  bronchscope. 

diameter  by  8  inches  (20  cm.)  long  for  adults,  and  one  1/5  inch 
(5  mm.)  in  diameter  by  5  1/2  inches  (14  cm.)  long  for  children;  and 
for  upper  tracheo-bronchoscopy  a  tube  7/25  inch  (7  mm.)  in  diame- 
ter by  18  inches  (45  cm.)  long  for  adults,  and  one  1/5  inch  (5 
mm.)  in  diameter  by  8  inches  (20  cm.)  long  for  children. 


Fig.  417. — Jackson's  secretion  aspirator. 

In  Killian's  instruments  (Fig.  415)  illumination  is  supplied  from 
an  electric  head  light.     In  the  Jackson  tubes  (Fig.  416)  the  illu- 
mination is  supplied  by  a  small  electric  light  at  the  distal  end  of 
the  instrument.     These   latter   are   somewhat   easier   to   use   than 
26 


402 


THE  LARYNX  AND  TRACHEA 


Killian's  instruments.  In  addition,  the  Jackson  instruments  are 
provided  with  a  conduit  to  which  is  attached  a  suction  apparatus 
and  exhaust  pump,  for  the  purpose  of  removing  secretions  that 
may  collect  and  obscure  the  view  (Fig.  417).  For  inserting  these 
instruments,  a  special  split  tube  (Fig.  418),  resembling  that  used 


Fig.  418. — Jackson's  separable  speculum  for  passing  the  bronchoscope.  The 
handle,  ab,  for  use  when  the  patient  is  in  a  sitting  posture;  c,  shows  the  arrangement 
of  the  lamp  at  the  distal  end. 

in  direct  laryngoscopy,  is  supplied  which  is,  removed  in  two  halves 
after  the  bronchoscope  has  entered  the  glottis. 

A  portable  battery  with  rubber-covered  cords,  a  mouth-gag,  a 


Fig.  419. — Accessory  instruments  for  tracheo-bronchoscopy. 

Sajous  applicator,  variously  shaped  forceps,  applicators  for  applying 
cocain  or  drugs  to  '.he  mucous  membrane,  hooks,  etc.,  for  the  removal 
of  foreign  bodies  through  the  instrument,  and  a  tracheotomy  set 


DIRECT    TRACHEO-BRONCHOSCOPY 


403 


(see  page  426)  are  required.     The  operator  should  also  be  provided 
with  a  number  of  extra  lamps  to  replace  those  that  may  burn  out. 

Asepsis. — Strict  asepsis  in  all  details  is  absolutely  necessary. 
The  tubes  and  accessory  instruments  are  boiled,  the  lighting  appara- 
tus is  sterilized  by  immersion  in  alcohol  or  in  a  i  to  20  carbohc  acid 
solution  followed  by  rinsing  in  alcohol,  and  the  rubber-covered  bat- 
tery cords  are  wiped  off  with  bichlorid  solution.  The  hands  of  the 
operator  and  assistants  should  be  as  thoroughly  cleansed  as  for  any 
operation.  On  account  of  the  danger  of  sepsis  from  the  mouth,  the 
patient's  teeth  should  be  brushed  and  the  mouth  well  cleansed  with 


Fig.  420. — The  position   of   the   patient   and   the   assistant   for   upper   tracheo- 
bronchoscopy.    (After  Jackson.) 

an  antiseptic  wash  before  passing  the  instruments.  A  tube  employed 
in  the  upper  operation  should  not  be  used  for  lower  bronchoscopy 
without  resterilization. 

Preparation  of  the  Patient. — If  general  anesthesia  is  to  be  em- 
ployed, the  patient  should  be  prepared  according  to  the  usual  method 
(page  2).  In  any  case,  the  operation  should  be  performed  on  an 
empty  stomach.  For  lower  tracheo-bronchoscopy,  the  neck,  if 
hairy,  should  be  shaved  and  painted  with  tincture  of  iodin. 

Position  of  the  Patient. — If  done  under  local  anesthesia,  upper 
tracheo-bronchoscopy  may  be  performed  with  the  patient   in  the 


404 


THE    LARYNX    AND    TRACHEA 


upright  position.  The  patient  sits  on  a  low  stool,  with  the  head  ex- 
tended backward  as  far  as  possible  and  the  tongue  projected  forward. 
An  assistant  holds  the  head  from  behind  and  steadies  the  mouth- 
gag,  w^hile  the  operator  stands  in  front.  When  a  general  anesthetic 
is  employed,  and  in  all  cases  of  lower  bronchoscopy,  the  patient 
should  be  in  the  dorsal  position  on  a  table,  the  front  of  which  is 
slightly  elevated,  wath  the  head  hanging  over  the  edge  of  the  table, 
in  which  position  it  is  supported  by  an  assistant  who  takes  care  of  the 
mouth-gag,  as  shown  in  Fig.  420. 


SUDEOrSPiCULUM  R[»o/[D 


Fig.  421. — Showing  the  various  steps  in  upper  bronchoscopy.      (After  Jackson.) 

Anesthesia. — In  children,  general  anesthesia  is  necessary.  In 
adults,  preliminary  cocainization  of  the  pharynx  and  larynx  with  a  4 
per  cent,  solution  of  cocain,  followed  by  a  20  per  cent,  solution  of 
cocain,  appHed  to  the  larynx  and  trachea  is  in  most  cases  sufficient, 
unless  the  patient  is  very  excitable,  although  general  anesthesia 
renders  the  operation  easier  in  any  case.  Even  when  general  anes- 
thesia is  used,  cocain  should  be  applied  by  means  of  cotton  applica- 
tors to  the  larynx  and  trachea  before  the  introduction  of  the  tube,  to 
avoid  dangerous  reflexes  from  stimulation  of  the  endings  of  the  su- 
perior laryngeal  nerve. 


DIRECT    TEACHEO-BRONCHOSCOPY 


405 


Technic. — i.  Upper  Tracheo-bronchoscopy. — With  the  patient  in 
the  proper  position,  and  the  parts  cocainized,  the  mouth  is  widely 
opened  and  the  mouth-gag  is  inserted  and  given  to  the  assistant  to 
maintain  in  position.  The  larynx  and  vocal  cords  are  exposed  by 
introducing  a  split  tube  spatula,  as  for  direct  laryngoscopy  (page 
398).  Thebronchoscope,  well  lubricated  with  sterile  vaseHn,  andwith 
the  illumination  properly  turned  on,  is  passed  through  the  split  tube 
as  far  as  the  epiglottis  under  the  guidance  of  the  operator's  eye. 
The  operator  notes  the  vocal  cords  and  instructs  the  patient  to  breathe 
deeply,  and,  while  the  cords  are  open  during  inspiration,  the  instru- 
ment is  gently  passed  through  the  glottis  until  it  enters  the  trachea. 
The  split  tube  is  then  separated  and  removed.  As  the  bronchoscope 
is  advanced,  the  mucous  membrane  in  front  should  be  anesthetized 
by  means  of  a  20  per  cent,  solution  of  cocain  applied  with  cotton 
swabs  on  a  long  applicator.     The  instrument  is  thus  slowly  passed 


Fig.  422. — Lower  bronchoscopy.     (Modified  from  Ballanger.) 

to  the  bifurcation  of  the  trachea,  and  the  parts  are  examined  in  detail 
as  the  tube  advances. 

To  enter  the  right  bronchus,  the  instrument  should  be  turned 
toward  the  left  angle  of  the  patient's  mouth,  and  toward  the  right 
side  if  the  left  bronchus  is  to  be  entered.  By  very  careful  and  gentle 
manipulations  with  the  tube,  and  by  using  the  smallest  sizes,  the 
secondary  and  even  the  third  division  of  the  bronchi  may  be  inspected 
by  one  especially  skilled  in  this  work. 

During  the  examination,  secretions  or  blood  may  be  removed  by 
means  of  cotton  wrapped  on  long  applicators  or  by  the  special  aspirat- 
ing apparatus  supplied  with. the  instrument,  the  manipulation  of 
which  is  entrusted  to  an  assistant.  In  this  way  the  entire  mucous 
membrane  lining  the  trachea  may  be  examined,  foreign  bodies  located 
and  removed,  and  lesions  treated  by  direct  application. 


4o6 


THE    LARYNX   AND    TRACHEA 


2.  Lower  Tracheo-bronchoscopy. — Low  tracheotomy  is  first  per- 
formed as  described  on  page  432.  After  all  the  bleeding  has  been 
controlled,  a  Trousseau  dilator  is  inserted  and  the  tracheal  wound  is 
held  open.  The  mucous  membrane  of  the  trachea  is  then  cocainized 
with  a  20  per  cent,  solution  of  cocain.  A  short  bronchoscope,  with 
the  illumination  turned  on,  is  then  introduced,  and  the  instrument 
is  advanced  under  the  guidance  of  the  operator's  eye,  which  is  applied 
at  the  end  of  the  instrument.  As  soon  as  the  bifurcation  of  the  tra- 
chea is  reached,  the  tube  may  be  directed  into  either  bronchus  by 


Fig.  423. — Instruments  for  probing  the  larynx.      I,  Laryngeal  probe;  2,  laryngeal 
mirror;  3,  alcohol  lamp;  4,  head  mirror. 

gentle  manipulation.  The  patient's  head  is  turned  sideways,  and,  if 
the  right  bronchus  is  to  be  entered,  the  tube  is  inserted  on  the  left 
side  of  the  head;  if  the  left  bronchus  is  to  be  examined,  the  tube  is 
inserted  at  the  right  side  of  the  head.  The  bronchi  should  be  anesthet- 
ized, as  before,  in  advance  of  the  instrument  with  cocain  applied  upon 
long  applicators  through  the  instrument,  and  the  examination  pro- 
ceeded with  as  above. 

The  after-treatment  of  the  patient  consists  in  inserting  a  tracheot- 
omy tube  which  is  worn  for  several  days.     After  the  removal  of  this 


PALPATION  BY   THE    PROBE  407 

tube,  the  wound  should  be  carefully  protected  by  a  gauze  dressing  and 
cleansed  daily,  being  allowed  to  heal  from  the  bottom  up. 

PALPATION  BY  THE  PROBE 

Palpation  by  the  probe  is  of  value  in  determining  the  consistency 
and  extent  of  new  growths,  the  depth  and  size  of  ulcerations,  the 
presence  of  necrosed  cartilage,  and  the  sensibility  of  the  mucous 
membrane. 

Instruments. — A  laryngeal  mirror,  an  alcohol  lamp,  a  head  light, 
and  a  laryngeal  probe  are  necessary  (Fig.  423). 

Asepsis.  -The  probe  should  be  boiled  and  the  laryngeal  mirror 
sterilized  by  immersion  in  a  i  to  20  solution  of  carbolic  acid,  then 
rinsed  off  in  sterile  water  and  dried  before  use. 

Position  of  Patient. — The  patient  is  in  the  same  position  as  for 
ordinary  laryngoscopy. 

Anesthesia. — The  larynx  should  be  cocainized  by  spraying  or  by 
the  application  of  a  lo  per  cent,  solution  of  cocain. 

Technic. — The  tongue  is  protruded  and  held  by  the  patient  with  a 
cloth,  and  the  laryngeal  mirror  is  warmed  and  inserted  in  such  a 
position  that  a  good  view  of  the  larynx  is  obtained.  The  probe  is 
held  in  the  operator's  right  hand  and  is  introduced  into  the  patient's 
mouth  turned  on  its  side,  with  the  laryngeal  portion  horizontal  and 
the  handle  in  the  angle  of  the  mouth  until  it  almost  reaches  the  pos- 
terior pharyngeal  wall  (see  Fig.  424).  It  is  then  brought  into  the 
natural  position,  with  the  laryngeal  portion  vertical  and  the  handle  in 
the  mid-line,  the  point  of  the  instrument  lying  in  the  pharynx  behind 
the  epiglottis.  By  raising  the  handle  of  the  instrument,  the  point  is 
then  brought  forward  over  the  arytenoids.  By  directing  the  point  of 
the  probe,  guided  by  the  image  in  the  mirror,  the  diseased  areas  are 
then  explored  (see  Fig.  425).  In  performing  this  manipulation,  it 
must  be  remembered  that  the  image  in  the  mirror  is  reversed,  so  that 
movements  of  the  instrument  will  likewise  appear  reversed,  and  that 
the  distance  between  the  arytenoids  and  the  vocal  cords  is  much 
greater  than  appears  in  the  image. 

In  introducing  any  laryngeal  instrument,  such  as  applicators, 
brushes,  forceps,  etc.,  of  the  same  shape  as  the  laryngeal  probe,  that 
is,  with  long  handles  and  a  laryngeal  piece  at  right  angles,  or  nearly  so, 
with  the  handle,  the  same  technic  should  be  employed;  otherwise,  if 
the  instrument  is  introduced  into  the  mouth  with  the  laryngeal  end 
held  vertically,  it  is  usually  impossible  to  insert  the  laryngeal  portion 
between  the  palate  and  base  of  the  tongue. 


4o8  THE  LARYNX  AND  TRACHEA 

SKIAGRAPHY 

Skiagraphy  is  employed  as  an  adjunct  to  other  diagnostic  meas 
ures  for  locating  metal  and  other  foreign  bodies  which  are  impene- 
trable to  the  rays,  and  also  for  localizing  certain  growths  of  greater 
density  than  the  surrounding  tissues. 

Therapeutic  Measures 
THE  LARYNGEAL  SPRAY 

The  laryngeal  spray  is  employed  for  the  purpose  of  cleansing  and 
for  medication.  Cleansing  of  the  larynx  is  frequently  required  for 
the  removal  of  purulent  secretions  the  result  of  syphihticor  tubercular 
ulcerations,  and  to  soften  and  wash  away  the  crusts  which  are  often 
an  accompaniment  of  fetid  laryngitis.  Whenever  possible,  spraying 
of  the  larynx  should  be  done  by  the  surgeon  himself,  as  it  can  thus 
be  performed  by  the  aid  of  direct  vision  in  a  thorough  manner.  If 
this  is  not  possible,  the  patient  must  be  very  carefully  instructed  in 
the  use  of  the  instrument. 

Medication  of  the  larynx  may  be  required  in  the  treatment  of 
acute  and  chronic  inflammations,  ulcerations,  etc.,  and  according  to 
the  indications  of  the  individual  case,  remedies  with  an  antiseptic, 
astringent,  sedative,  stimulating,  or  caustic  action  are  employed. 
These  may  be  used  in  the  form  of  watery  or  oily  solutions.  The 
great  sensitiveness  of  the  laryngeal  mucous  membrane  should  be 
kept  in  mind  in  making  any  topical  application,  and  the  use  of  very 
irritating  drugs  should  be  avoided. 

Instruments. — It  is  important  to  select  a  spray  that  will  not  expel 
the  solution  in  such  a  powerful  stream  as  to  produce  irritation  and 
possibly  add  to  the  local  inflammation.  The  Davidson,  the  Whitall 
Tatum  (see  Fig.  336),  and  the  De  Vilbiss  atomizers  (see  Fig.  337)  are 
simple  and  very  efficient  instruments.  They  should  be  provided  with 
a  laryngeal  nozzle,  which  turns  downward.  The  air  current  may  be 
supplied  by  a  rubber  compression  bulb  or  by  means  of  a  compressed- 
air  apparatus  (see  Fig.  338). 

A  head  mirror,  a  laryngeal  mirror,  and  proper  illumination  will 
also  be  required  when  the  spraying  is  to  be  done  by  the  operator  under 
direct  vision. 

Solutions. — For  cleansing  purposes,  the  alkaline  solutions  recom- 
mended on  page  327  for  use  in  the  nose  may  be  employed.     For 


THE    DIRECT   APPLICATION    OF    REMEDIES  409 

topical  applications  to  the  larynx,  the  formulae  of  antiseptic,  astrin- 
gent, sedative,  and  stimulating  solutions  given  on  page  331,  for  use 
in  the  nose,  may  be  employed  according  to  the  indications. 

Temperature. — The  solutions  should  always  be  used  warm,  at 
a  temperature  of  about  100°  F.  (38°  C), 

Anesthesia. — When  the  parts  are  very  sensitive,  preliminary 
spraying  with  a  10  per  cent,  solution  of  cocain  may  be  required. 

Technic. — -The  patient  is  directed  to  open  his  mouth  widely  and 
to  protrude  his  tongue,  which  he  may  hold  forward  with  the  fingers  of 
his  right  hand  if  desired.  The  operator  then  warms  and  introduces 
a  laryngeal  mirror,  holding  it  so  as  to  obtain  a  good  view  of  the  parts. 
Then,  with  his  right  hand,  he  introduces  the  spray  nozzle  into  the 
mouth,  and  with  the  aid  of  the  mirror  passes  it  behind  the  epiglottis 
and  depresses  the  tip  so  that  it  points  toward  the  diseased  area. 
When  the  nozzle  is  in  proper  position,  the  mirror  is  removed  and  the 
bulb  of  the  spray  is  sharply  compressed,  the  patient  being  instructed 
to  phonate  while  this  is  being  done.  The  spray  is  then  immediately 
removed,  as  the  patient  will  cough  and  want  to  expectorate.  When 
performed  for  cleansing  purposes,  the  spraying  should  be  repeated 
several  times  until  the  larynx  is  well  washed  out.  Each  time  the 
patient  coughs,  mucus,  purulent  secretion,  and  crusts,  which  have 
been  softened  and  separated  by  the  spray,  will  be  expelled. 

When  the  spraying  is  carried  out  by  the  patient,  the  mouth  is 
widely  opened  and  the  tongue  protruded  as  before.  The  spray  noz- 
zle, held  in  the  patient's  right  hand,  is  then  introduced  well  back  of  the 
tongue,  with  the  tip  directed  downward  and  forward  over  the 
larynx,  and,  while  the  patient  phonates,  the  bulb  is  sharply  com- 
pressed. In  employing  oily  preparations,  the  patient  should  take  an 
inspiration  at  the  moment  of  compressing  the  bulb,  so  as  to  aid  in 
drawing  the  solution  into  the  larynx.  Until  the  patient  becomes 
skilled  in  the  introduction  of  the  spray,  it  is  well  for  him  to  perform 
the  operation  standing  in  front  of  a  mirror. 

THE  DIRECT  APPLICATION  OF  REMEDIES 

This  method  is  indicated  when  it  is  desired  to  apply  remedies  to 
some  particular  spot,  especially  when  strong  stimulants  or  caustics 
are  used.  Liquids  may  be  appHed  by  means  of  swabs  or  brushes. 
SoHd  caustics  should  be  fused  on  a  probe.  The  application  should 
be  made  with  the  aid  of  a  laryngeal  mirror,  and  great  care  must  be 
taken  to  avoid  bruising  the  tissues  or  causing  trauma. 


410 


THE  LARYNX  AND  TRACHEA 


Instruments. — For    the    application    of    liquids,    a    camel's-hair 
brush,  mounted  on  a  wire  which  is  bent  at  right  angles  about  21/2 


Fig.  424  — Method  of  inserting  the  laryngeal  applicator. 


Fig.  425. — Shows  the  method  of  making  direct  applications  to  the  larynx  by  the  aid 

of  the  laryngeal  mirror. 

to  3  inches  (6  to  7  cm.)  from  the  end  and  inserted  into  a  handle,  a 
Sajous  appUcator  (see  Fig.  413),  or  an  ordinary  laryngeal  applicator 
wrapped  with  cotton  may  be  employed.     In  making  use  of  the  latter, 


INSUFFLATIONS  4 1 1 

care  sliould  be  taken  that  the  cotton  is  wrapped  tightly  about  the  end 
of  the  instrument,  so  that  there  is  no  danger  of  its  falHng  off  and  sHp- 
ping  into  the  larynx. 

Solid  caustics,  as  silver  nitrate  and  chromic  acid,  may  be  applied 
fused  on  the  end  of  a  laryngeal  probe,  as  described  on  page  334. 

Anesthesia. — The  parts  should  be  anesthetized  by  means  of  a  10 
per  cent,  solution  of  cocain  applied  by  means  of  a  spray  or  on  a  cotton 
applicator. 

Technic. — -The  laryngeal  mirror  is  warmed  and  introduced  by 
the  operator's  left  hand,  so  as  to  obtain  a  clear  view  of  the  parts  to  be 
medicated.  If  secretion  or  mucus  be  present,  the  parts  should  be 
first  cleansed  by  spraying.  The  applicator  is  then  dipped  in  the 
solution  to  be  applied,  and  any  excess  of  fluid  is  removed  to  prevent  it 
from  running  into  the  trachea.  This  precaution  is  especially  neces- 
sary when  using  strong  solutions  or  caustics.  The  instrument,  held 
in  the  operator's  right  hand,  is  then  introduced  into  the  mouth,  with 
the  curved  surface  held  first  horizontally  (Fig.  424),  and  then,  as  soon 
as  the  tip  of  the  instrument  reaches  the  pharynx,  turned  to  a  vertical 
position.  The  applicator  is  then  guided  to  the  desired  spot  by  the 
aid  of  the  laryngeal  mirror  (Fig.  425).  The  application  should  be 
made  with  great  gentleness  and  care  and  the  instrument  quickly 
removed. 

The  appHcation  of  acids  is  carried  out  in  the  same  manner,  any 
excess  of  acid  being  immediately  neutralized  by  the  application  of  a 
solution  of  bicarbonate  of  soda,  gr.  xxx  (2  gm.)  to  the  ounce  (30  c.c). 
A  dusting  powder  may  finally  be  applied  to  the  cauterized  area. 

INSUFFLATIONS 

Powders  may  be  applied  to  the  larynx  by  means  of  a  special 
insufflator.  They  are  of  use  chiefly  in  cases  of  ulceration,  where  a 
sedative  or  antiseptic  action  is  desired.  A  combination  of  nosophen, 
aristol,  europhen,  iodoform,  etc.,  with  finely  powdered  starch,  stearate 
of  zinc,  or  powdered  acacia  as  a  base,  are  usually  employed  in  the  pro- 
portion of  one  part  of  the  active  principle  to  two  parts  of  the  base. 
Small  amounts  of  morphin  or  cocain  may  also  be  combined  with  the 
base  and  applied,  when  indicated,  for  the  relief  of  pain. 

Instruments. — A  laryngeal  powder  blower,  a  head  light,  a  laryn- 
geal mirror,  an  alcohol  lamp,  and  suitable  illumination  are  necessary. 
The  insufflator  shown  in  Fig.  426  is  very  convenient,  as  with  it  the 
amount  of  powder  may  be  accurately  measured,  and  the  instrument 
may  be  manipulated  with  one  hand. 


412 


THE  LARYNX  AND  TRACHEA 


Technic. — The  laryngeal  mirror  is  warmed  and  properly  inserted 
into  the  pharynx,  so  that  a  good  view  of  the  parts  to  be  medicated  is 
obtained.  The  insufflator,  filled  with  the  desired  amount  of  powder, 
is  inserted  in  the  mouth  and  carried  back  to  the  larynx  under  the 
guidance  of  the  image  in  the  mirror.  When  in  proper  position,  a 
sudden  compression  on  the  bulb  forces  out  the  powder  and  deposits  it 
on  the  diseased  surface.  If  it  is  desired  to  carry  the  powder  deep  into 
the  larynx,  the  patient  should  be  requested  to  phonate  at  the  moment 
of  compressing  the  bulb. . 


Fig.  426. 


-Instruments  for  applying  powders  to  the  larynx,     i,  Powder  blower;  2, 
laryngeal  mirror;  3,  alcohol  lamp;  4,  head  mirror. 


STEAM    INHALATIONS 

By  means  of  steam  inhalations  the  active  principle  of  certain  drugs 
that  are  readily  volatilized  by  heat  may  be  brought  into  contact  with 
the  mucous  membrane  of  the  respiratory  tract  and  carried  beyond 
the  larynx  to  the  trachea  and  bronchi.  The  effect  of  the  steam  itself 
is  also  valuable,  for  it  acts  as  an  anodyne  upon  inflamed  mucous  mem- 
branes by  supplying  moisture  and  so  reHeving  the  heat  and  dryness  of 
congestion.  In  the  latter  stages  of  an  inflammation  the  steam,  fur- 
thermore, dilutes  and  assists  in  removing  secretions.  Steam  inhala- 
tions are  thus  of  great  value  in  congestion  and  edema  of  the  larynx, 


STEAM   INHALATIONS 


413 


croup,  membranous  laryngitis,  and  bronchitis.  They  are  especially 
serviceable  in  softening  the  thick  tenacious  secretion  of  chronic 
laryngitis. 


Fig.  427. — Croup  kettle. 


Fig.  428. — Steam  atomizer. 
Fig.  429. — Steam  inhaler  improvised  from  a  coffee-pot>. 

The  Inhaler. — When  it  is  simply  intended  to  convey  the  vapor  to 
the  vicinity  of  the  patient,  a  croup  kettle  with  a  long  spout,  such  as 


414 


THE    LARYNX   AND   TRACHEA 


shown  in  Fig.  427,  is  most  convenient.  For  direct  inhalation,  more 
or  less  elaborate  forms  of  apparatus  are  manufactured  (Fig.  428),  but 
a  coffee-pot  with  a  funnel  of  heavy  paper  placed  in  the  top  makes  a 
simple  and  efficient  inhaler  (Fig.  429). 

Formulary. — Sedative,  stimulating,  or  antiseptic  drugs  are  the 
ones  usually  employed  for  inhalation.  These  include  tincture  of 
benzoin  compound  in  the  strength  of  i  5  (4  c.c.)  to  the  pint  (500  c.c.) ; 
creosote,  5  to  10  TU  (0.3  to  0.6  c.c.)  to  the  pint  (500  c.c);  ol. 
cubebae,  sT([  (0.3  c.c.)  to  the  pint  (500  c.c);  spirits  camphori.  sTIft 


Fig.  430. — Crib  arranged  for  steam  inhalations.      (After  Kerley., 

(0.3  c.c.)  to  the  pint  (500  c.c);  ol.  pinus  sylvestris,  5  Tn,(  0.3  c.c.) 
to  the  pint  (500  c.c),  etc. 

Temperature. — When  directly  inhaled,  the  vapor  should  not  be  of 
a  higher  temperature  than  150°  F.  (65°  C).  If  used  at  too  high  a 
temperature,  irritation  of  the  mucous  membrane  may  be  produced 
and  there  is  danger  of  the  steam  scalding  the  face. 

Technic. — Into  an  inhaler  a  pint  (500  c.c.)  of  nearly  boiling  water 
is  placed  and  the  proper  quantity  of  the  drug  is  added.  The  patient 
then  places  his  nose  over  the  cone  and  inhales  the  escaping  vapor, 
taking  about  six  to  eight  breaths  a  minute.  The  inhalation  should 
not  be  continued  for  more  than  five  or  ten  minutes  at  a  time.  It  may 
be  employed  three  or  four  times  daily.  The  treatment  should  be 
carried  out  in  a  warm  room,  i.e.,  at  a  temperature  of  about  68° 
F.,  (20°  C.)  and  care  should  be  taken  to  protect  the  patient  from 
draughts.     As  the  steam  relaxes  the  mucous  membrane  and  renders 


DRY   INHALATIONS  415 

the  patient  susceptible  to  cold,  he  should  not  be  allowed  out  of  doors 
for  several  hours  afterward. 

In  using  the  croup  kettle,  the  steam  may  be  delivered  into  the 
room  or  directly  over  the  patient.  When  the  latter  method  is  used, 
it  is  well  to  cover  the  bed  of  the  patient  with  a  sheet  arranged  in  the 
form  of  a  tent  and  raised  sufficiently  high  to  permit  a  free  circulation 
of  air,  the  nozzle  of  the  croup  kettle  being  inserted  under  one  side  of 
the  tent  and  the  water  kept  boiling  (Fig.  430). 

DRY    INHALATIONS 

These  are  useful  in  diseases  of  the  upper  respiratory  tract  for  those 
who  cannot  tolerate  the  steam  inhalations.  The  method  has  an 
advantage  over  steam  inhalations  in  that  the  patient  does  not  have  to 
remain  in  the  house  afterward. 


Fig.  431. — Inhalation  mask. 

The  Inhaler. — A  special  mask  made  of  woven  metal,  which  accu- 
rately fits  the  mouth  and  which  is  provided  with  a  sponge  upon  which 
the  medication  is  dropped,  is  employed  (Fig.  431). 

Formulary. — Any  of  the  very  volatile  oils,  such  as  thymol,  men- 
thol, eucalyptol,  etc.,  may  be  employed. 

Technic. — Twenty  or  thirty  drops  (1.25  to  2  c.c.)  of  the  oil  are 
placed  upon  the  sponge  of  the  mask  and  the  latter  is  placed  over  the 
patient's  face  and  is  secured  by  strings  fastened  back  of  the  head  and 
neck.  The  patient  inhales  through  the  mask  by  means  of  the  mouth, 
and  exhales  through  the  nose.  The  mask  may  be  worn  for  about  half 
an  hour  two  or  three  times  a  day. 

INTUBATION  OF    THE  LARYNX 

Intubation  of  the  larynx,  an  operation  devised  by  O'Dwyer, 
consists  in  the  introduction  of  a  tube  into  the  larynx  for  the  purpose  of 
securing  free  respiration  in  the  presence  of  obstruction  in  the  larynx 


4i6 


THE    LARYNX    AND    TRACHEA 


or  upper  portion  of  the  trachea.  It  is  an  operation  which  gives 
prompt  rehef  without  the  necessity  of  cutting  and  without  producing 
any  loss  of  blood  or  shock.  It  is  less  terrifying  to  the  patient 
than  the  tracheotomy  and  the  after-care  is  not  so  troublesome. 
Anesthesia  is  not  required  nor  is  any  previous  preparation  of  the 
patient  required.  Special  instruments,  however,  are  necessary,  and 
the  feeding  of  the  patieiit  is  often  troublesome  and,  while  not  a  diffi- 
cult operation  in  itself,  it  requires  special  training  for  its  skilful  per- 
formance which  is  best  learned  by  practice  upon  the  cadaver. 


Fig.  432. — O'Dwyer  intubation  instruments,  i,  Tube  with  obturator  in  place* 
2,  tube  and  obturator  separated;  3,  gauge;  4,  mouth  gag;  5,  introducer;  6,  silk 
thread;  7  extractor. 


Indications. — The  operation  was  originally  devised  for  the  relief 
of  obstruction  to  respiration  in  cases  of  laryngeal  diphtheria  and  has 
now  almost  entirely  supplanted  tracheotomy  in  such  cases.  The 
immediate  indications  are  dyspnea  accompanied  by  cyanosis,  depres- 
sion of  the  suprasternal  and  supraclavicular  spaces  on  inspiration, 
and  sinking  in  of  the  lower  portion  of  the  chest.  Intubation  is  also 
employed  in  laryngeal  stenosis  from  other  causes  for  the  purpose  of 
producing  gradual  dilatation  of  the  parts,  progressively  larger 
tubes  being  introduced  and  worn  for  a  few  days  at  a  time. 

Instruments. — The  instruments  required  are  an  O'Dwyer  intuba- 
tion set  including  seven  metal  or  hard-rubber  tubes,  an  introducer, 


INTUBATION  OF  THE  LARYNX  417 

an  extractor,  a  mouth  gag,  and  a  gauge  indicating  the  size  of  the  tubes 
according  to  the  age  of  the  patient  (Fig.  43  2) .  Although  these  instru- 
ments have  been  modified  and  attempts  have  been  made  to 
improve  upon  them,  those  originally  designed  by  O'Dwyer  give  the 
best  results. 

The  intubation  tube  has  an  expanded  head  prolonged  backward 
in  the  form  of  a  flange  to  prevent  it  from  slipping  through  the  vocal 
cords  and  a  fusiform  bulb  in  the  middle  to  aid  in  keeping  the  tube  in 
position.  In  the  anterior  portion  of  the  head  a  perforation  is  pro- 
vided for  the  attachment  of  a  piece  of  silk  thread.  The  lower  end  of 
the  tube  is  rounded  off  and  oval.  Each  tube  is  provided  with  an 
obturator  which  can  be  screwed  on  to  the  introducer.  The  free 
extremity  of  the  obturator  ends  in  a  protuberance  which  projects 
beyond  the  tube  and  prolongs  the  latter  into  a  rounded  extremity  to 
aid  in  its  introduction. 

The  introducer,  or  intubator,  consists  of  a  handle  in  which  is  set  a 
rod,  to  the  extremity  of  which  the  obturator  may  be  screwed.  A 
sliding  joined  tube  fits  over  this,  which  can  be  pushed  forward  by  a 
small  knob  set  on  the  handle  of  the  instrument,  thereby  detaching 
the  intubation  tube  from  the  obturator  when  the  former  is  in  proper 
position  in  the  larynx. 

The  extractor,  or  extubator,  is  an  instrument  supplied  with  jaws 
which  fit  into  the  lumen  of  the  tube,  and  when  opened  by  pressure 
upon  a  lever  engage  the  tube  with  sufficient  force  to  permit  its  removal 
from  the  larynx. 

Asepsis. — The  instruments  should  be  sterilized  before  use. 

Position  of  the  Patient. — The  child,  with  its  arms  at  its  sides,  is 
wrapped  from  chin  to  foot  in  a  sheet  or  blanket  and  is  supported  upon 
the  lap  of  a  nurse  in  a  sitting  posture  facing  the  operator  with  its  feet 
held  between  the  nurse's  knees  and  its  head  resting  on  her  right 
shoulder.  An  assistant  should  stand  behind  and  grasp  the  child's 
head  firmly,  lifting  upward  as  though  holding  the  child  by  the  head, 
thus  extending  the  child's  head  as  far  as  possible  (Fig.  433).  Some 
operators,  however,  prefer  to  intubate  with  the  patient  in  a  horizontal 
position  and  with  a  small  sand-bag  placed  under  the  back  of  the  neck. 

Technic. — A  tube  of  a  size  corresponding  to  the  age  of  the  patient 
is  selected  and  is  properly  threaded  mth  a  piece  of  silk  2  or  3  feet 
(60  to  90  cm.)  long.  Then,  with  the  obturator  in  place,  the  tube  is 
screwed  on  the  introducer  in  such  a  manner  that  its  projecting 
flange  lies  behind  and  faces  away  from  the  operator.  The  mouth  gag 
is  next  inserted  between  the  patient's  jaws  on  the  left  side  and  is  held 


4i8 


THE    LARYNX   AND   TRACHEA 


in  place  by  the  assistant  who  supports  the  child's  head.  The  opera- 
tor, with  his  eyes,  nose,  and  mouth  protected  against  possible  infec- 
tion in  diphtheria  cases,  faces  the  patient  and  inserts  his  left  index- 


FlG.  433. — Position  of  child  for  intuabation  and  method  of  holding. 


Fig.  434. — Intubation.     First  step,  showing  the  method  of  drawing  the  epiglottis 

forward. 

finger  into  the  mouth,  hooking  up  the  epiglottis  (Fig.  434).  In  doing 
this  care  should  be  taken  to  keep  the  finger  to  the  left  side  and  out  of 
the  way  as  much  as  possible.  The  operator  then  takes  the  introducer 
with  the  tube  attached  in  his  right  hand,  holding  it  as  follows:  The 
thumb  pressed  against  the  button  on  the  upper  side  of  the  handle,  the 


INTUBATION  OF  THE  LARYN^X 


419 


index-iinger  around  the  hook  on  the  under  surface  of  the  instrument, 
and  the  loop  of  silk  wound  over  his  little  finger,  as  shown  in  Fig. 
435.     He  then  slowly  introduces  the  tube  into  the  mouth  in  the  me- 


FiG.   435. — Showing  the  intubation  tube  on  the  introducer  and  the  method   of 

holding  the  latter. 

dian  Kne,  hugging  the  center  of  the  tongue  and  keeping  the  handle  of 
the  instrument  at  first  well  down  on  the  chest  of  the  patient  (Fig. 
436).     When  the  end  of  the  tube  reaches  the  epiglottis  (Fig.  437),  the 


Fig.  436. — Intubation.     Second    step,   introducing   the   tube   into   the   patient's 

mouth. 

handle  is  sharply  elevated,  so  that  the  tube  is  brought  into  a  vertical 
position  (Fig.  438).  If  the  handle  of  the  instrument  is  not  sufficiently 
elevated,  the  tube  will  point  toward  the  entrance  of  the  esophagus 
which  it  will  be  apt  to  enter  during  the  next  maneuver  (Fig.  439).  At 


420 


THE  LARYNX  AND  TRACHEA 


the  same  time  the  finger  of  the  operator  is  moved  to  the  posterior 
portion  of  the  larynx,  resting  on  the  arytenoid  cartilages  to  prevent 
the  tube  from  entering  the  esophagus.  The  tube  is  then  gently 
pushed  through  the  chink  of  the  glottis  and  on  into  the  larynx,  guided 
by  the  operator's  finger.     No  force  whatever  should  be  used. 


Fig.  437. — Third  step  in  intubation.       FiG.  438. — Fourth  step  in  intubation. 

As  soon  as  the  tube  is  in  proper  position,  the  operator's  forefinger 
is  placed  on  its  head  holding  it  in  place  while  the  button  on  the  handle 
of  the  instrument  is  pushed  forward,  thus  disengaging  the  obturator 
from    the    tube    (Fig.    440).     The    intubator    with    the    obturator 


Fig.  439. — Showing  a  faulty  position  Fig.  440. — Fifth  step  in  intubation 

of  the  tube,  due  to  the  handle  of  the  in-  withdrawing     the    introducer     while 

troducer  not  being  raised  sufficient]}-  index-finger  holds  the  tube  in  place, 
high. 

attached  is  then  removed,  and  the  tube  is  pushed  well  into  the  larynx 
by  the  finger  (Fig.  441).  Not  more  than  five  to  ten  seconds  should  be 
consumed  in  introducing  the  tube,  for  while  this  is  being  done  breath- 
ing is  interfered  with;  if  the  tube  cannot  be  promptly  inserted,  the 
operation  should  be  suspended  and  a  second  attempt  made  after 
allowing  the  child  time  to  recover  its  breath. 


INTUBATION  OF  THE  LARYNX 


421 


If  the  tube  is  properly  placed,  there  may  be  at  first  some  cough, 
but  the  breathing  rapidly  becomes  easier,  and  the  cyanosis  is  quickly 
relieved.  After  the  tube  is  in  position,  it  is  well  to  wait  for  ten  or 
fifteen  minutes,  to  make  sure  that  there  is  no  obstruction  to  free 


Fig.  441. — Sixth  step  in  intubation, 
showing  the  index-finger  pushing  the 
tube  well  into  the  larynx. 


Fig.  442. — Showing  the  intubation 
tube  in  place. 


respiration.  When  certain  that  the  tube  is  properly  placed  in  the 
larynx,  the  mouth  gag  is  reinserted,  and  one  strand  of  silk  is  cut  near 
the  angle  of  the  mouth,  and  the  string  is  withdrawn,  the  forefinger 
being  placed  on  the  tube  to  maintain  it  in  position  (Fig.  443).     Some 


Fig.  443. — Final  step  in  intubation,  removing  the  string  from  the  tube. 

operators  prefer  to  leave  the  string  attached  for  the  removal  of  the 
tube  in  case  of  sudden  emergency.  If  this  is  done,  the  string  should 
be  brought  out  the  corner  of  the  mouth,  hooked  over  the  ear,  and 
secured  by  adhesive  plaster.     This  method  has  the  disadvantage, 


422 


THE  LARYNX  AND  TRACHEA 


however,  of  furnishing  a  chance  for  the  child  to  remove  the  tube  if  it 
gets  hold  of  the  string.  ? 

Should  t  he  tube  be  placed  in  the  esophagus  by  mistake,  there  will 
be  no  relief  to  the  dyspnea  and  the  cyanosis,  there  will  be  an  absence 
of  cough,  and  the  string  of  silk  will  be  seen  to  gradually  shorten  as  the 
tube  passes  down  the  esophagus.  In  such  a  case,  the  tube  should  be 
removed  by  pulling  on  the  string,  and,  after  waiting  a  sufficient  time 


Fig.  444. — Method  of  feeding  an  intubation  patient  with  the  head  lowered. 

or  the  patient  to  recover  from  the  excitement  attending  the  opera- 
tion, it  should  be  reintroduced. 

In  some  instances,  the  tube  may  become  occluded  by  pushing  the 
false  membrane  ahead  of  it.  If  this  occurs,  the  tube  should  be 
removed  at  once,  and,  if  the  obstructing  membrane  is  not  expelled 
from  the  larynx  and  cannot  be  extracted  and  suffocation  seems 
imminent,  tracheotomy  should  be  performed.  Care  should  be  taken 
not  to  select  too  small  a  tube,  for  it  may  be  expelled  by  coughing  or 
may  escape  into  the  trachea. 

Feeding  Intubated  Patients. — The  tube  renders  swallowing  diffi- 
cult, and  the  patients  are  only  able  to  take  liquid,  or,  at  most,  semi- 
solid food.     As  a  rule,  by  having  the  patient  lie  with  the  head  lowered, 


IXTUEATIOX  OF  THE  LARYNX 


423 


fluids  will  pass  along  th.e  roof  of  the  mouth  to  the  posterior  pharyngeal 
wall,  and  wall  enter  the  esophagus,  and,  if  given  slowly,  sufficient  food 
may  be  administered  in  this  way  (Fig.  444) ;  or  food  may  be  admin- 
istered by  having  the  patient  suck  up  the  food  through  a  tube  while 
lying  face  downward  upon  the  lap  of  a  nurse.  In  some  cases,  where 
the  patient  refuses  foods,  liquids  may  be  administered  by  means  of  the 
stomach-tube  passed  through  the  mouth  or  by  means  of  a  soft-rubber 
catheter  passed  into  the  stomach  through  the  nose  (page  502),  though 
by  the  continued  use  of  the  latter  method  there  is  danger  of  producing 
infection  of  the  middle  ear.  Rectal  feeding  may  be  combined  with 
the  above  if  indicated. 


When  to  Remove  the  Tube. — The  tube  should  always  be  removed 
as  soon  as  possible,  as  its  prolonged  use  may  produce  ulceration  of  the 
larynx.  In  cases  of  diphtheria,  where  antitoxin  has  been  adminis- 
tered, the  tube  may  be  removed  in  three  to  seven  days,  depending  to 
some  extent  upon  the  age  of  the  patient,  being  left  in  for  longer  inter- 
vals in  very  young  children.  If  the  tube  becomes  occluded  at  any 
time,  it  must  be  removed  -^dthout  delay,  cleaned,  and  then  reintro- 
duced. When  the  tube  is  to  be  permanently  removed,  the  physician, 
after  extracting  it,  should  wait  sufficiently  long  to  see  that  respiration 
does  not  become  impeded  and  necessitate  its  reintroduction. 

Technic  of  Extubation.— The  patient  is  placed  and  held  in  the 
same  position  as  for  introduction  of  the  tube.  The  mouth  gag  is 
inserted,  and  the  operator  passes  his  left  index-finger  into  the  mouth 
and  over  the  epiglottis  until  it  rests  on  the  head  of  the  tube.  The 
extubator,  held  in  the  operator's  right  hand,  is  then  introduced  with 


424  THE  LARYNX  AND  TRACHEA 

its  jaws  closed,  by  the  same  maneuvers  employed  in  introducing  the 
intubator,  until  its  tip  is  felt  by  the  finger  on  the  tube.  It  is  then 
carefully  guided  into  the  lumen  of  the  tube.  By  pressing  the  lever  on 
top  of  the  handle,  the  jaws  of  the  instrument  are  separated  and  obtain 
a  secure  hold  on  the  tube,  so  that  it  may  be  easily  withdrawn  (Fig. 
417).  To  accomplish  this,  the  tube  must  be  lifted  at  first  vertically 
upward.  The  handle  of  the  instrument  is  then  depressed,  and  the 
tube  is  brought  out  by  a  reversal  of  the  movements  of  intubation. 

In  an  emergency,  when  the  tube  becomes  obstructed,  it  may  be 
possible  to  remove  it  by  enucleation,  especially  if  the  tube  be  short. 
This  consists  in  placing  the  thumb  of  the  right  hand  on  the  larynx 
beneath  the  end  of  the  tube  while  the  patient's  head  is  extended,  and 
with  a  quick  motion  of  the  head  forward,  at  the  same  time  exerting 
upward  pressure  on  the  larynx,  the  tube  is  expelled  into  the  mouth. 

TRACHEOTOMY 

The  term  tracheotomy  is  generally  used  to  designate  the  operation 
of  opening  into  the  air-passages  at  some  point  between  the  sternum 
and  thyroid  cartilage.  To  be  exact,  however,  the  term  should  be 
limited  to  operations  below  the  cricoid  cartilage,  while  above  that 
point,  that  is,  in  the  cricothyroid  space,  the  operation  is  called  lar^-n- 
gotomy.  Tracheotomy  is  subdivided  into  the  high  operation  when 
the  opening  is  made  above  the  isthmus  of  the  thyroid  gland,  and  into 
low  tracheotomy  when  the  operation  is  performed  below  this  point. 

Indications. — Tracheotomy  is  indicated  for  the  relief  of  obstruc- 
tive dyspnea,  which  may  be  the  result  of  any  one  of  the  following 
conditions:  The  formation  of  pseudomembrane;  the  presence  of 
foreign  bodies;  the  presence  of  growths  within  the  larynx  or  trachea 
or  external  to  these  structures;  edema  of  the  larynx;  spasm  of  the 
larynx;  rapid  swelling  of  the  tonsils  and  pharynx;  injuries  to 
the  larynx  and  trachea,  such  as  contusions,  fractures,  burns,  cicatri- 
cial stenosis,  etc.  For  the  relief  of  obstruction  from  diphtheritic 
membranes,  however,  intubation  should,  as  a  rule,  be  the  operation 
of  choice,  tracheotomy  being  reserved  for  those  cases  where  intuba- 
tion fails,  as  when  the  membrane  extends  down  low  in  the  trachea, 
and  where  the  attending  physician  does  not  possess  the  necessary 
skill  for  intubation,  or  where  the  necessary  instruments  for  intubation 
are  not  available.  Tracheotomy  may  also  be  required  for  the 
removal  of  foreign  bodies  from  the  larynx,  trachea,  and  bronchi,  for 
the  administration  of  tracheal  anesthesia  in  operations  upon  the 


TRACHEOTOMY 


425 


mouth,  pharynx,  jaws,  or  larynx,  and  as  a  preliminary  to  laryngect- 
omy and  lower  tracheo-bronchoscopy. 

Choice  of  Operation. — The  choice  between  laryngotomy,  high 
tracheotomy,  and  low  tracheotomy  depends  upon  the  seat  of  the 
obstruction  and  also  upon  the  age  of  the  patient  and  the  necessity  for 
haste.  Of  the  three,  laryngotomy  is  the  most  easily  and  rapidly 
performed.  It  thus  becomes  the  operation  of  choice  in  a  sudden 
emergency  where  the  obstruction  is  located  in  the  larynx  and  where 
there  is  demand  for  haste  in  order  to  avoid  imminent  suffocation  or 
where  the  proper  instruments  and  assistants  are  lacking.     It  is  not, 


Pig.  446. — The  location  of  the  incisions  in  laryngotomy  and  tracheotomy.      (After 

Bickham.) 
a.  Thyroid  cartilage;  h,  incision  for  laryngotomy;  c  and  e,  branches  of  superior 
thyroid  arteries;  d,  cricoid  cartilage;/,  incision  for  high  tracheotomy;  g,  thyroid 
gland;  }i,  incision  for  low  tracheotomy;  ?,  pneumogastric  nerve;  j,  sterno-mastoid 
muscle;  k,  inferior  thyroid  veins;  /,  sterno-thyroid  muscle. 

however,  a  suitable  operation  to  be  performed  upon  those  under 
thirteen  years  of  age,  on  account  of  the  small  size  of  the  cricothyroid 
space,  nor  should  it  be  performed  for  the  relief  of  conditions  requiring 
the  wearing  of  a  tube  for  any  length  of  time,  on  account  of  the  proxim- 
ity of  the  vocal  cords  and  their  liabiHty  to  injury  by  the  tube. 

On  account  of  the  small  number  of  important  vessels  encountered, 
and  the  greater  ease  with  which  the  trachea  is  reached,  high  tracheot- 
omy is  preferable  to  the  low  operation  where  the  location  of  the 
trouble  permits.  It  is  the  operation  of  choice  for  children  and  in 
cases  of  diphtheria  where  a  tube  has  to  be  worn  for  some  time. 


426 


THE    LARYNX    AND    TRACHEA 


Low  tracheotomy  may  be  required  for  the  removal  of  foreign  bod- 
ies from  the  bronchi,  for  lower  tracheo-bronchoscopy,  for  the  relief 
of  threatened  suffocation  from  occlusion  of  the  trachea  by  tumors  of 
the  thyroid,  etc.  It  requires  more  skill  in  its  performance  than  does 
the  high  operation,  as  in  the  lower  portion  of  the  neck  the  trachea  is 
more  deeply  placed  and  important  structures  at  the  root  of  the  neck 
are  in  close  proximity. 

Instruments. — The  instruments  that  should  be  provided  include: 
a  scalpel,  a  narrow  bistoury,  scissors,  two  sharp  retractors,  two  ten- 


f 


Fig.  447.^Instruments  for  tracheotomy. 
I,  Scalpel;  2,  curved  bistoury;  3,  scissors;  4,  retractors;  5,  tenaculum;  6, artery 
clamps;  7,  thumb  forceps;  8,  needle-holder;  9,  Trousseau  tracheal  dilator;  10,  tra- 
cheotomy tube;  II,  catheter;  12,  tracheal  forceps;  13,  needles;  14,  No.  2  catgut. 


acula,  artery  clamps,  two  pairs  of  thumb  forceps,  tracheal  forceps,  a 
Trousseau  tracheal  dilator,  a  flexible-rubber  catheter,  tracheotomy 
tubes  and  tape,  a  needle-holder,  two  curved  cutting-edge  needles,  and 
No.  2  catgut  for  ligatures  and  sutures  (Fig.  447).  In  an  emergency, 
where  delay  would  mean  the  loss  of  the  patient's  life,  the  operation 
may  be  performed  by  the  aid  of  a  pocket-knife  and  two  hairpins  bent 
in  the  shape  of  a  hook  to  hold  the  trachea  open  until  the  proper  tube 
can  be  obtained. 


TRACHEOTOMY 


427 


Tracheotomy  tubes  of  several  sizes  and  with  different  curves 
should  be  provided  so  that  one  suitable  for  the  individual  case  may  be 
at  hand.  A  silver  tube,  somewhat  flattened  from  side  to  side,  with- 
out fenestrae,  and  with  a  movable  inside  tube,  is  preferable  (Fig.  448). 


Fig.  448. — Tracheotomy  tube. 


Fig.  449. — Tracheotomy  tube  improvised 
from  rubber  tubing. 


With  some  tubes  an  obturator  is  supplied  as  an  aid  to  insertion.  For 
an  adult,  a  No.  5  or  6  tube  will  usually  suffice;  for  a  child  under  two, 
a  No.  2  tube  should  be  provided;  for  a  child  from  two  to  four,  a 
No.  3;  and  for  one  over  four,  a  No.  4.     In  an  emergency  a  tube  may 


Fig.   450. — Position  of  patient  for  laryngotomy  and  tracheotomy. 

be  improvised  by  bending  a  piece  of  rubber  tubing  into  the  required 
shape,  as  shown  in  Fig.  449.  For  laryngotomy,  a  tube  shorter  than 
the  ordinary  tracheotomy  tube,  and  flattened  from  before  backward, 
is  employed. 

Asepsis. — The  instruments  are  sterilized  by  boiling  or,  in  an  emer- 
gency, by  immersion  in  a  i  to  20  carbolic  acid  solution.     The  hands 


428  THE  LARYNX  AND  TRACHEA 

of  the  operator  and  his  assistants  shouki  be  prepared  with  the  same 
care  as  for  any  operation. 

Position  of  the  Patient. — This  should  be  such  as  to  bring  the  neck 
into  the  greatest  possible  prominence.  The  patient  is  therefore 
placed  in  a  strong  light  on  a  firm  flat  table  with  a  cushion  under  his 
shoulders,  thus  allowing  the  head  to  hang  back,  but  not  so  far  as  to 
put  the  trachea  under  tension  or  to  flatten  it  and  impede  respiration 
(Fig.  450).  In  an  emergency,  the  patient's  head  may  be  simply 
alowed  to  hang  over  the  edge  of  the  table  or  a  lounge. 

A  child  should  be  wrapped  in  a  blanket  or  sheet,  with  its  arms  at 
the  sides.  The  legs  should  also  be  secured  and  an  assistant  should  be 
provided  to  hold  the  head  in  proper  position. 

Anesthesia. — In  adults,  local  anesthesia  with  cocain  or  novocain 
is  sufficient.  A  0.2  per  cent,  solution  of  cocain  is  employed  for  the 
skin,  and  a  o.i  per  cent,  solution  for  deeper  infiltration.  When  there 
is  occasion  for  great  haste  in  the  presence  of  unconsciousness  or  dys- 
pnea with  marked  and  increasing  cyanosis,  an  anesthetic  may  be 
dispensed  with,  as  in  such  cases  the  sense  of  pain  is  much  blunted  or 
aboHshed. 

In  young  children,  local  anesthesia  is  not  followed  by  good  results, 
as  the  infiltration  alone  terrifies  the  child  and  produces  struggling, 
which  adds  to  the  dyspnea.  If  air  enters  the  lungs  at  all,  chloroform 
given  slowly  is  the  best  anesthesia,  ether  being  apt  to  irritate  the 
mucous  membrane  and  produce  laryngeal  spasm,  thus  adding  to  the 
dyspnea. 

Preparations. — If  hairy,  the  neck  should  be  shaved.  The  skin  is 
sterilized  by  painting  with  tincture  of  iodin. 

Technic. — i.  Laryngotomy. — The  thyroid  and  cricoid  cartilages 
are  identified,  and,  with  the  larynx  supported  between  the  thumb  and 
forefinger  of  the  operator's  left  hand,  an  incision  about  i  1/2  inches 
(4  cm.)  long  is  made  through  the  skin,  exactly  in  the  median  line  of 
the  neck,  extending  from  the  lower  portion  of  the  thyroid  cartilage  to 
below  the  cricoid  cartilage.  The  superficial  fascia,  platysma,  and 
deep  fascia  are  divided,  and  the  sternohyoid  and  sternothyroid  mus- 
cles are  separated  at  the  inner  borders  and  held  apart  by  retractors. 
The  connective  tissue  and  veins  underlying  these  structures  are  then 
separated,  all  veins  being  clamped  or  hgated  before  division.  The 
cricothyroid  membrane  is  thus  brought  into  view.  The  thyroid 
cartilage  is  steadied  with  a  tenaculum,  while  the  cricothyroid 
membrane  is  transversely  incised  by  means  of  a  sharp,  narrow-pointed 
bistoury  near  the  upper  border  of  the  cricoid  cartilage,  so  as  to  avoid 


TRACHEOTOMY 


429 


the  cricothyroid  artery,  which  runs  along  the  upper  border  of  the 
space  below  the  thyroid  cartilage  (Fig.  451).  If  the  situation  of  this 
vessel  is  such  that  injury  to  it  or  its  branches  cannot  be  avoided,  it 
should  be  tied  between  two  ligatures  before  the  membrane  is  incised. 
In  opening  the  membrane,  the  incision  must  be  carried  deep  enough 
to  include  the  mucous  membrane  lining  it,  otherwise  the  laryngotomy 
tube  may  be  pushed  in  between  the  two  structures  and  not  into  the 
larynx  at  all.  The  wound  is  held  apart  with  two  small  retractors  or 
a  tracheal  dilator,  and  the  foreign  body  which  may  be  causing  the 
obstruction  is  removed  by  means  of  tracheal  forceps.  If  there  is  not 
sufficient  room  to  remove  the  foreign  body  through  this  incision,  the 


Fig.  451. — Opening  the  cricothyroid  membrane  in  laryngotomy. 
(After  Bickham.) 


cricoid  cartilage  may  be  cut.  The  laryngotomy  tube  is  then  care- 
fully introduced  and  is  secured  in  place  by  tapes  passing  around  the 
patient's  neck,  a  small  square  pad,  split  to  its  center,  being  interposed 
between  the  skin  and  the  flange  of  the  tube.  A  stitch  or  two  may  be 
placed  at  the  upper  and  lower  angles  of  the  wound  to  bring  them  to- 
gether, if  necessary.  Even  where  the  obstruction  is  immediately 
relieved,  it  is  preferable  in  any  case  to  insert  a  tube  for  a  time  until  the 
tissues  become  more  or  less  adherent,  so  as  to  avoid  subcutaneous 
emphysema. 

2.  High  Tracheotomy. — The  thyroid  cartilage  is  grasped  between 
the  thumb  and  forefinger  of  the  left  hand,  so  as  to  steady  the  trachea, 
and  with  the  right  hand  a  vertical  incision  i  1/2  to  2  inches  (4  to  5 


43° 


THE    LARYNX   AND    TRACHEA 


cm.)  long  is  made  exactly  in  the  median  line,  extending  from  the  cri- 
coid cartilage  to  a  Uttle  below  the  isthmus  of  the  thyroid  gland  (Fig. 
452).  The  skin  and  superficial  and  deep  fascia  are  incised,  and  the 
anterior  jugular  veins  which  are  encountered  in  the  upper  part  of  the 
incision,  together  with  any  communicating  branches  of  the  superior 
thyroid  veins,  are  caught  in  forceps  and  ligated.  The  sternohyoid 
and  sternothyroid  muscles  are  thus  exposed,  and  should  be  separated 
along  their  inner  borders  and  retracted  to  the  ?ides.  As  these  luscles 
are  pulled  apart,  the  isthmus  of  the  thyroid  gland  and  the  deep  cervi- 
cal fascia  covering  the  trachea  appear.  This  fascia  is  then  divided 
from  the  lower  border  of  the  cricoid  cartilage  by  a  transverse  incision 
curved  downward  at  the  extremities.  The  fascia  is  then  stripped 
from  the  trachea  and  retracted  dow^nward,  and  with  it  the  isthmus  of 
the  thyroid  gland,  thus  exposing  the  rings  of  the  trachea.     If  the 


Fig.  452. — Exposing  the  trachea  in  high  tracheotomy. 

thyroid  isthmus  is  very  large,  two  Hgatures  may  be  placed  about  it,  on 
each  side  of  the  median  line,  to  control  the  hemorrhage,  and  the  isth- 
mus with  the  deep  fascia  is  incised  vertically  and  retracted  to  each 
side.  A  tenaculum  is  then  inserted  beneath  the  cricoid  cartilage,  and 
is  held  by  an  assistant  so  as  to  steady  the  trachea.  If  without  a  tube, 
it  is  well  to  apply  retraction  sutures  on  either  side  of  the  trachea  before 
opening  the  latter.  For  this  purpose  a  full  curved  needle,  threaded 
with  fairly  strong  silk,  is  passed  on  each  side  through  the  membrane 
below  the  ring  to  be  cut,  emerging  through  the  membrane  above.     A 


TRACHEOTOMY 


431 


sharp  narrow  bistoury,  with  its  cutting  edge  up,  is  inserted  through 
the  membrane  below  the  second  ring  of  the  trachea,  and  the  latter  is 


Fig.  453. — Opening  the  trachea  in  high  tracheotomy.     (After  Bickham.) 


Fig.  454. — Method  of  inserting  the  tracheotomy  tube. 

incised  in  the  median  line  as  far  up  as  the  cricoid  cartilage,  care  being 
taken  to  include  the  mucous  membrane  of  the  trachea  in  this  incision 


432 


THE    LARYNX   AND    TRACHEA 


(Fig.  453).  The  edges  of  the  tracheal  opening  are  separated  with 
tracheal  forceps,  or  the  wound  is  held  open  by  the  retraction  sutures, 
if  they  were  previously  inserted,  and  the  tracheotomy  tube,  with  its 
cannula,  is  carefully  passed  through  the  open  wound  into  the  trachea 
(Fig.  454).  If  there  is  no  great  urgency,  all  bleeding  should  be 
arrested  before  the  trachea  is  opened,  but  where  haste  is  important 
this  may  be  omitted  until  the  tube  is  introduced. 

When  the  tube  has  been  properly  placed,  a  pad  of  gauze  is  inter- 
posed between  the  skin  and  the  flange  of  the  tube,  and  the  latter  is 
securely  held  in  place  by  tapes  passing  from  each  side  of  the  flange 
around  the  neck  (Fig.  455). 

In  cases  of  diphtheria,  as  soon  as  the  trachea  is  opened  a  large 
amount  of  mucus  and  membrane  is  usually  expelled,  and  it  is  of 
advantage  in  such  cases  not  to  insert  the  tube  at  once,  but  to  hold  the 


Fig.  455. — Showing  the  tracheotomy  tube  in  place.      (Stoney.) 


tracheal  wound  open  and  allow  the  membrane  to  be  expelled.  What 
is  not  expelled  may  then  be  removed,  if  loose,  by  forceps.  The  dan- 
ger of  infection  from  the  patient's  coughing  bits  of  membrane  from 
the  tracheal  opening  into  the  face  of  the  operator  should  be  guarded 
against  by  the  operator  wearing  a  face  mask  or  by  holding  a  piece  of 
wet  gauze  over  the  wound. 

3.  Low  Tracheotomy. — The  trachea  is  steadied  with  the  thumb 
and  forefinger  of  the  left  hand,  and  a  vertical  incision  is  carried  from 
the  thyroid  cartilage  to  within  1/2  inch  (i  cm.)  of  the  sternal  notch. 
The  skin  and  superficial  and  deep  fascia  are  incised,  and  the  inferior 
thyroid  veins,  or  other  vessels  that  may  be  in  the  way,  are  ligated  and 


TRACHEOTOMY  433 

divided.  The  sternohyoid  and  sternothyroid  rmiscles  are  separated 
in  the  median  line  and  are  retracted  to  each  side.  The  deep  cervical 
fascia  is  divided  vertically  downward  from  the  lower  border  of  the 
isthmus  of  the  thyroid  gland,  and  is  retracted  laterally,  notching  it 
transversely  on  each  side  if  necessary  to  obtain  more  space.  Care 
must  be  taken  in  deepening  the  incision  at  the  lower  angle  of  the 
wound  not  to  injure  the  innominate  vein  which  may  bulge  up  above 
the  sternal  notch.  The  isthmus  of  the  thyroid  gland  is  pulled  well  up 
out  of  the  way  by  means  of  a  retractor,  and  while  the  trachea  is 
steadied,  an  incision  is  carried  upward  through  two  or  more  of  the 
lowermost  rings  by  means  of  a  narrow  bistoury.  The  edges  of  the 
tracheal  wound  are  then  retracted,  and  the  tube  is  inserted  and 
secured  in  place  as  previously  described. 

After-care. — The  opening  of  the  tube  should  be  covered  with  a 
piece  of  gauze  moistened  with  normal  salt  solution,  and  the  patient 


Fig.  456. — Intracannular  alligator  forceps.     (Fowler.) 

kept  in  a  room  at  a  temperature  of  about  65°  to  70°  (18°  to  21°  C). 
If  the  operation  is  performed  for  inflammatory  conditions,  the  atmos- 
phere should  be  kept  moist  by  the  steam  from  a  croup  kettle  directed 
so  as  to  play  over  the  tracheal  opening  (see  page  412).  At  first,  the 
inner  tube  should  be  removed  every  two  or  three  hours  and  be 
cleansed;  later,  less  frequent  attention  will  be  required.  The  outer 
tube  should  be  removed  and  cleansed  as  often  as  necessary,  this  being 
done  by  the  surgeon  himself.  Its  reintroduction  will  be  greatly  facili- 
tated by  the  use  of  a  guide.  Any  membrane  or  mucus  that  may  col- 
lect at  the  mouth  of  the  tube  should  be  promptly  removed.  Secre- 
tions blocking  the  tube  may  be  removed  by  means  of  a  small  catheter 
and  a  suction  syringe.  Membrane  may  be  removed  from  the  interior 
of  the  tube  with  alHgator  forceps  (Fig.  456)  introduced  through  the 
cannula.  If  this  is  not  possible,  the  tracheotomy  tube  should  be  with- 
drawn and  the  obstruction  removed. 

Removal  of  the  Tube. — In  cases  of  diphtheria  the  tube  may  be 
permanently  removed  as  soon  as  there  is  free  respiration  through  the 
28 


434  THE  LARYNX  AND  TRACHEA 

larynx  with  the  tracheal  wound  closed.  This  is  usually  possible  in 
from  five  days  to  one  week.  When  tracheotomy  is  employed  for 
the  removal  of  foreign  bodies,  etc.,  the  tube  should  be  worn  for 
twenty-four  hours  at  least.  This  allows  time  for  the  oozing  to  cease 
and  averts  the  danger  of  blood  entering  the  trachea  and  the  escape  of 
air  into  the  subcutaneous  tissues. 

Complications. — Broncho-pneumonia  is  a  common  complication 
even  when  not  due  to  an  extension  of  the  diphtheritic  process.  Infec- 
tion of  the  wound  may  follow  in  diphtheria  cases  and  may  spread  into 
the  loose  connective  tissue  of  the  neck,  producing  a  cellulitis;  or  the 
infection  may  work  down  and  cause  septic  pneumonia.  An  improp- 
erly fitting  tube  frequently  causes  ulceration  of  the  trachea  from 
pressure.  This  complication  should  be  immediately  remedied  by  the 
substitution  of  a  new  tube.  Emphysema  may  occur  if  the  tube  is 
removed  too  soon;  it  has  also  been  produced  from  injury  to  the  pos- 
terior or  lateral  walls  of  the  trachea.  Hemorrhage  from  congested 
veins  may  at  times  be  severe;  in  the  majority  of  cases,  however,  the 
bleeding,  which  may  be  profuse  before  the  trachea  is  opened,  stops 
spontaneously  as  soon  as  respiration  is  re-established. 


CHAPTER  XVI 
THE  ESOPHAGUS 

A natomic  Considerations 

The  esophagus  extends  from  the  lower  border  of  the  cricoid  cartil- 
age to  about  the  level  of  the  ensiform  cartilage  or,  in  other  words, 
from  the  level  of  the  disk  between  the  fifth  and  sLxth  cervical  verte- 
bras to  the  tenth  dorsal  vertebra.  Its  entire  length  is  about.  lo  inchs- 
(25  cm.),  while  the  distance  from  the  upper  incisor  teeth  to  the  cardiac 
end  measures  about  16  inches  (40  cm.) .  Antero-posteriorly  the  esoph- 
agus presents  a  slight  curve  with  the  concavity  forward,  as  it  fol- 
lows the  direction  of  the  spinal  column.  Laterally,  it  has  the  follow- 
ing curves:  from  its  starting  point  it  turns  slightly  to  the  left, 
projecting  as  much  as  1/2  inch  (i  cm.)  to  the  left  of  the  trachea;  it 
then  descends  in  front  of  the  spine,  at  first  behind  the  arch  of  the  aorta 
and  then  lying  to  the  right  of  the  aorta,  finally  curving  in  front  of,  and 
a  little  to  the  left  of,  the  aorta  to  pass  through  the  diaphragm  (Fig. 
457).  In  its  course,  the  esophagus  has  in  front  of  its  upper  portion 
the  trachea;  while  below  it  is  crossed  by  the  left  bronchus  and  the 
arch  of  the  aorta.  The  pericardium  and  the  left  vagus  nerve  also 
lie  in  front.  Posteriorly,  it  rests  upon  the  spinal  column  and  the  tho- 
racic duct;  about  3  inches  (7  cm.)  from  the  diaphragm  it  crosses  the 
aorta.     On  either  side  it  is  in  relation  with  the  pleura. 

The  esophagus  measures  about  3/4  inch  (19  mm.)  in  diameter, 
but  a  number  of  constrictions  in  its  caHber  have  been  described,  the 
most  marked  being  as  follows:  (i)  at  its  commencement,  6  inches 
(15  cm.)  from  the  incisor  teeth;  (2)  at  a  point  10. inches  (25  cm.) 
from  the  incisor  teeth,  where  it  is  crossed  by  the  left  bronchus;  and 
(3)  at  a  point  16  inches  (40  cm.)  from  the  incisor  teeth,  where  it 
passes  through  the  diaphragm  (Fig.  458).  At  these  points  the  caKber 
of  the  tube  measures  about  1/2  inch  (i  cm.).  The  measurements, 
curves,  and  constrictions  of  the  esophagus  are  important  to  remember 
in  the  passage  of  instruments  and  with  reference  to  the  lodgment  of 
foreign  bodies. 

435 


436 


THE    ESOPHAGUS 

Diagnostic   Methods 


The  methods  available  for  examination  of  the  esophagus  include : 
(i)  auscultation,  (2)  percussion,  (3)  external  palpation,  (4)  instru- 
mental examination,  (5)  inspection  through  the  esophagoscope,  and 
(5)  the  use  of  the  X-rays.     The  first  three  of  these  methods  are  of 


Fig.  457.  Fig.  458. 

Fig.  457. — The  course  and  relations  of  the  esophagus  viewed  from  behind. 

Fig.  458. — The  normal  narro wings  of  the  esophagus.  (Eisendrath.)  i,  At 
its  junction  with  the  pharynx;  2,  opposite  the  bifurcation  of  the  bronchi;  3,  at 
the  diaphragm. 

very  limited  cUnical  value,  while  the  use  of  the  esophagoscope  is  of 
doubtful  value  except  in  the  hands  of  an  expert,  so  that  in  the  major- 
ity of  cases  we  have  to  rely  upon  the  use  of  bougies  and  sounds  or  the 
X-rays. 

As  in  examination  of  other  regions,  a  careful  history  of  the  case 
should  precede  any  local  examination. 


EXAMINATION   BY    SOUNDS    AND   BOUGIES  437 

AUSCULTATION 

Auscultation  is  performed  by  listening  with  a  stethoscope  over  the 
course  of  the  esophagus  while  the  patient  swallows  liquids.  The 
usual  points  for  auscultation  are  upon  the  left  side  of  the  spine  oppo- 
site the  ninth  or  tenth  dorsal  vertebra,  or  just  to  the  left  of  the  ensi- 
form.  Normally,  during  the  passage  of  liquids  down  the  tube  two 
sounds  are  heard:  one  directly  after  the  patient  swallows  and  the 
other  six  or  seven  seconds  later,  as  the  food  is  forced  into  the  stomach 
through  the  cardia.  If  stenosis  exists  at  the  cardia  or  a  stricture  be 
present  at  some  point  higher  up,  this  second  sound  will  be  absent  or 
delayed;  in  paralysis  of  the  esophagus  it  will  likewise  be  absent.  At 
times  it  may  also  be  possible  to  recognize  by  auscultation  the  stop- 
page of  the  fluid  when  it  reaches  the  point  of  stricture. 

PERCUSSION 

Percussion  may  reveal  the  presence  of  large  tumors,  dilatations,  or 
diverticula.  In  the  latter  condition,  dulness  may  be  present  only 
after  eating  and  be  absent  when  the  sac  is  empty.  A  tympanitic 
note  will  be  obtained  when  the  diverticulum  sac  contains  gas. 

PALPATION 

External  palpation  is  extremely  limited  in  usefulness,  as  it  is  only 
applicable  to  the  cervical  portion  of  the  esophagus.  By  means  of 
palpation  one  may  be  able  to  discover  hard  foreign  bodies,  tumors, 
enlarged  glands,  enlargements  of  the  thyroid,  as  well  as  any  pressure 
tenderness  along  the  esophagus.  Diverticula  full  of  food  may  be  thus 
distinguished  and  mapped  out,  and  not  infrequently  it  is  possible  to 
empty  the  diverticulum  sac  of  its  contents  by  pressure. 

By  internal  palpation  with  the  index-finger,  foreign  bodies  lodged 
in  the  entrance  of  the  esophagus  and  strictures,  new  growths,  etc., 
at  the  same  location  may  be  recognized. 

EXAMINATION  BY   SOUNDS  AND  BOUGIES 

The  sound  and  bougie  are  employed  for  diagnostic  as  well  as  thera- 
peutic purposes.  By  their  use  valuable  information  may  be  obtained 
as  to  the  location  of  foreign  bodies,  strictures,  diverticula,  etc. ;  fur- 
thermore, the  degree  of  a  stenosis  may  be  accurately  determined. 
The  passage  of  esophageal  instruments  is  not  difficult.     Gentleness 


438  THE    ESOPHAGUS 

only  should  be  employed  in  manipulation,  however,  since,  if  due  care 
is  not  exercised  in  this  direction,  false  passage  may  be  readily  made 
through  the  esophagus  into  the  rnediastinum;  especially  is  such  an 


Fig.   459. — Cylindrical  esophageal  sound. 

accident  possible  if  the  coats  of  the  esophagus  are  already  weakened 
by  disease. 

Before  any  attempt  is  made  to  pass  instruments,  a  thorough  phys- 
ical examination — including  the  vascular  system — should  be  made. 
In  the  presence  of  aortic  aneurysm,  recent  hemorrhage  from  the  esoph- 
agus or  stomach,  acute  inflammation  of  the  esophagus,  and  after 


Fig.  460. — Conical  esophageal  sound. 

recent  ulceration,  the  use  of  esophageal  instruments  is  contraindi- 
cated.  In  cases  of  advanced  pulmonary  or  cardiac  disease  and  cir- 
rhosis of  the  liver,  instruments,  if  used,  should  be  employed  with 
great  caution. 

Instruments. — For  ordinary  examination,  graduated  esophageal 
bougies  and  bougies  a  boule  are  employed.     These  instruments  vary 


Fig.  461. — Olivary  bougies  a  boule  for  the  esophagus. 

in  length  from  24  to  32  inches  (60  to  80  cm.).  The  best  bougies  are 
hollow  and  are  made  of  a  gum-elastic  material,  so  that  when  warmed 
they  become  flexible  and  capable  of  being  bent  to  any  desired  shape. 

They  may  be  obtained  cylindrical  (Fig.  459)  or  conical  (Fig.  460)  in 
form.  In  their  stead,  however,  a  thick  rubber  stomach-tube  is  often 
utilized. 

The  bougie  a  boule  is  an  essential  instrument  if  the  length  of  a 
stricture  is  to  be  estimated.     It  consists  of  a  flexible  whalebone  shaft, 


EXAMINATION   BY    SOUNDS    AND   BOUGIES 


439 


to  the  end  of  which  metal  or  ivory  oKve-shaped  tips  of  different  sizes 
may  be  screwed  (Fig.  461).  The  shaft  should  be  marked  oil  in  an 
inch  or  centimetric  scale. 

In  cases  of  very  tight  stricture  filiform  bougies  of  whalebone  or 
woven  material  may  be  employed  to  determine  whether  the  stricture 
is  at  all  permeable.  They  may  be  introduced  into  the  stricture 
through  a  hollow  bougie  which  is  first  passed  to  the  face  of  the  stric- 
ture, or  they  may  be  inserted  through  an  esophagoscope. 

Asepsis. — Rubber  bougies  and  tubes  may  be  sterilized  by  boiling. 
The  gum-elastic  instruments,  unless  of  the  very  best  material,  are 
ruined  by  boiling  or  by  the  use  of  strong  antiseptics.  They  may  be 
rendered  sufficiently  aseptic  by  immersion  in  a  saturated  solution  of 


Fig.  462. — Shows  the  first  step  in  introducing  an  esophageal  bougie. 

boracic  acid,  after  first  thoroughly  washing  with  soap  and  water. 
The  hands  of  the  operator  should  also  be  clean. 

Position. — The  patient  is  seated  in  a  chair  with  the  head  thrown 
back  against  the  back  of  the  chair,  and  with  the  chin  raised  sufficiently 
to  make  the  passage  between  the  mouth  and  the  esophagus  as  straight 
a  line  as  is  possible.  The  surgeon  stands  in  front  of  the  patient, 
while,  if  desired,  an  assistant  may  steady  the  head  from  behind.  In 
the  case  of  a  child,  it  will  be  necessary  to  confine  its  arms,  either  hav- 
ing them  held  by  a  nurse  or  by  including  them  in  a  sheet  wrapped 
about  the  child's  body. 

Anesthesia. — In  an  adult  general  anesthesia  is  only  necessary  in 
exceptional  cases,  but  the  pharynx  and  larynx,  if  very  irritable  or  sen- 


440 


THE   ESOPHAGUS 


sitive,  may  be  brushed  over  with  a  5  or  lo  per  cent,  solution  of  cocain. 
Technic. — The  patient  is  seated  in  the  proper  position  with  a  towel 
about  the  neck  for  protection,  and  is  given  a  basin  to  catch  vomitus  or 
saliva.  A  soft,  flexible  sound  is  passed  as  follows:  the  bougie, 
moistened  with  water  and  held  in  the  operator's  right  hand  as  one 
would  a  pen,  is  passed  into  the  patient's  open  mouth  back  to  the  phar- 
ynx. The  patient  is  then  requested  to  swallow  and  the  instrument  is 
thus  advanced,  partly  by  the  act  of  swallowing  and  partly  by  the 


Fig.  463. — Introduction  of   an   esophageal  bougie  with   the   finger  holding  the 
tongue  and  epiglottis  forward. 

operator,  until  an  obstruction  is  reached  or  the  sound  enters  the 
stomaxh  (Fig.  462). 

Sometimes  when  a  rather  inflexible  bougie  is  employed  or  when  the 
tongue  is  thick  or  the  pharynx  is  swollen,  some  difficulty  may  be 
encountered  in  entering  the  esophageal  opening.  Under  such  con- 
ditions the  operator  passes  the  index-finger  of  his  left  hand  into  the 
patient's  widely  opened  mouth  to  a  point  well  back  of  the  tongue  and 
draws  the  latter  forward,  and  with  it  the  larynx,  so  that  the  esophagus 
may  be  more  easily  entered  (Fig.  463).  The  bougie  is  then  passed 
on  the  finger  as  a  guide  straight  back  in  the  median  line  to  the 


EXAMINATION  BY    SOUNDS   AND   BOUGIES 


441 


pharynx,  and,  hugging  the  posterior  wall  of  the  pharynx,  it  is  pushed 
steadily,  but  gently,  backward  and  downward  into  the  esophagus,  and 
thence  into  the  stomach,  unless  some  obstruction  be. encountered. 

The  patient  should  be  instructed  to  breathe  deeply  during  the 
passage  of  the  bougie,  even  if  gagging  is  produced,  and  he  should  be 
cautioned  not  to  bite  the  examiner's  finger  or  the  tube.  There  will 
usually  be  gagging  and  some  attempts  to  vomit  as  the  tube  is  inserted, 
but,  unless  very  distressing,  they  may  be  disregarded.  The  patient's 
head,  however,  should  be  bent  forward  over  a  basin  as  soon  as  the 
tube  is  well  within  the  esophagus  to  receive  any  vomitus,  mucus,  or 
saliva  (Fig.  464). 

If  dyspnea  and  cough  are  induced,  the  instrument  has  probably 
entered  the  larynx.     To  settle  this  point,  the  patient  should  be  told  to 


Fig.  464. — Shows  the  second  step  in  introducing  an  esophageal  bougie. 

phonate  "ee";  if  he  can  do  so,  one  may  be  sure  the  bougie  is  not  in 
the  larynx.  If  the  passage  of  the  tube  becomes  impeded  at  any  point, 
the  tube  should  be  slightly  withdrawn  and  then  again  pushed  gently 
onward,  when,  unless  a  stenosis  exists,  it  will  advance  without 
difficulty.  The  points  of  normal  constriction  at  which  a  bougie  may 
be  arrested  without  any  diseased  condition  being  present  should,  how- 
ever, be  kept  in  mind.  They  are:  (i)  6  inches  (15  cm.)  from  the 
upper  incisor  teeth;  (2)  10  inches  (25  cm.)  from  the  incisors;  and  (3) 
16  inches  (40  cm.)  from  the  incisors  (see  Fig.  458).  If  a  large  tube 
can  be  passed  into  the  stomach,  the  existence  of  a  stenosis  may  be 
ruled  out,  while  if  the  tube  passes  very  easily  without  any  sense  of 
resistance,  atony  or  paralysis  of  the  canal  is  presumable. 


44- 


THE   ESOPHAGUS 


Any  evidences  of  pain,  however,  produced  by  the  bougie  in  its 
descent  should  be  carefully  noted,  as  pointing  to  possible  inflamma- 
tion, ulceration,  or  malignancy.  When  the  bougie  meets  a  real 
obstruction  the  cause  should,  if  possible,  be  learned;  that  is,  whether 
due  to  spasm,  an  organic  stricture,  a  diverticulum,  a  new  growth,  or  a 
foreign  body.  No  force  should  be  employed  in  attempting  to  over- 
come the  obstruction,  but  the  bougie  should  simply  be  held  firmly  in 
place  for  several  minutes  or  be  slightly  withdrawn  when,  if  a  spasm 
were  the  cause,  it  can  be  advanced  as  relaxation  takes  place.  A  spas- 
modic stricture  will  always  disappear  if  the  patient  is  placed  under  the 
influence  of  a  general  anesthetic.     If  the  obstruction  does  not  yield, 


Fig.  465.  Fig.  466. 

Fig.  465. — Method  of  estimating  the  length  of  an  esophageal  stricture.  The 
bougie  a  boule  at  the  face  of  the  stricture. 

Fig.  466. — Method  of  estimating  the  length  of  an  esophageal  stricture.  The 
bougie  a  boule  is  withdrawn  until  its  base  is  arrested  at  the  distal  end  of  the 
stricture. 


the  bougie  is  removed  and  a  smaller  one  is  inserted;  and,  if  necessary, 
smaller  sizes  are  successively  introduced  until  one  is  selected  that  will 
pass  completely  through  the  stenosed  area  into  the  stomach.  In  this 
way  the  degree  of  stenosis  is  ascertained.  It  is  quite  important  in 
making  this  examination  to  insert  the  bougie  into  the  stomach,  as, 
otherwise,  a  second  stricture  below  the  first  may  be  overlooked. 

To  determine  the  length  of  a  stricture,  a  large  olive-tipped  sound 
is  inserted  until  it  reaches  the  face  of  the  stricture  (Fig.  465),  and  the 


EXAMINATIOX  BY    SOUNDS    AND   BOUGIES 


443 


distance  of  the  stenosis  from  the  upper  incisor  teeth  is  estimated  from 
the  markings  on  the  shaft  of  the  instrument.  The  bougie  is  then 
withdrawn  and  a  size  that  will  just  pass  is  inserted  well  through  the 
stricture.  Upon  withdrawing  the  instrument,  the  base  of  the  bulb 
catches  in  the  lower  rim  of  the  constriction  (Fig.  466),  and  the  dis- 
tance of  this  point  from  the  mouth  is  also  estimated.  By  subtracting 
the  first  of  these  measurements  from  the  second,  the  length  of  the  con- 
tracture is  readily  determined. 

It  is  often  possible  for  a  practised  hand  to  determine  the  consis- 
tency of  an  obstruction  from  the  sensation  imparted  by  contact  with 


Fig.  467.  Fig.  468.  Fig.  469. 

FiF.  467. — Shows  a  sound  passing  the  opening  of  a  diverticulum.  (After 
Gumprecht.) 

Fig.  468. — Shows  the  ease  with  which  a  sound  will  enter  a  diverticulum  when 
the  latter  is  full.     (After  Gumprecht.) 

Fig.  469. — Shows  the  ease  with  which  a  sound  follows  the  esophagus  when 
the  diverticulum  is  empty.     (After  Gumprecht.) 

the  tip  of  the  instrument.  By  means  of  a  metal-tipped  bougie  a  boule 
the  consistency  of  hard  foreign  bodies,  such  as  teeth,  coins,  bone,  etc., 
may  be  readily  recognized,  and  at  times  a  distinct  sound  may  be 
distinguished  when  the  two  come  in  contact. 

If  the  bougie  has  entered  a  diverticulum,  it  wiU  be  possible  to 
move  its  end  freely  in  difi'erent  directions,  and,  if  the  diverticulum  be 
located  high  up,  the  end  of  the  bougie  may  often  be  felt  in  the  neck. 
Again,  by  withdrawing  the  instrument  somewhat  so  as  to  disengage 
the  tip,  and  by  changing  its  direction  (Fig.  467),  it  can  frequently  be 
passed  by  the  diverticulum  into  the  stomach.     A  bougie  will  be  more 


444 


THE   ESOPHAGUS 


apt  to  enter  a  diverticulum  if  the  sac  be  full  (Fig.  468)  and  pass  to  the 
stomach  when  the  sac  'is  empty  (Fig.  469).  This  intermittent 
obstruction  to  the  passage  of  a  bougie  is  characteristic  of  a  diverticu- 
lum, and  is  a  point  in  the  differential  diagnosis  from  stricture. 
Another  method  of  differentiating  between  a  stenosis  and  a  diver- 
ticulum has  been  devised  by  Plummer,  It  is  carried  out  as  follows: 
The  patient  is  instructed  to  swallow  with  a  little  water  before 
bedtime  3  yards  (270  cm.)  of  button-hole  silk  and  in  the  morning  to 
swallow  3  yards  (270  cm.)  more  at  the  rate  of  a  foot  (30  cm.)  an  hour. 
By  the  afternoon  of  the  same  day,  if  there  is  an  opening  in  the  stric- 
ture or  diverticulum,  the  thread  will  have  been  carried  into  the  stom- 


FiG.  470.  Fig.  471. 

Fig.  470. — Esophageal  sound  passed  over  a  swallowed  thread  into  a  diverti- 
culum.    (After  Plummer.) 

Fig.  471. — Sound  lifted  _  out  of  the  diverticulum  by  tightening  the  thread. 
(After  Plummer.) 

ach  and  intestines  a  sufficient  distance  to  withstand  moderate  trac- 
tion without  being  withdrawn.  A  whalebone  bougie  with  an  olive 
tip,  through  which  is  an  opening  sufficiently  large  to  acconunodate  the 
thread,  is  then  passed  down  the  esophagus  on  the  thread,  which  is 
held  loosely,  until  an  obstruction  is  encountered.  If  this  obstruction 
be  due  to  stricture,  the  bougie  will  not  change  its  level  when  the 
thread  is  made  taut,  but,  if  the  sound  is  in  a  diverticulum  (Fig.  470), 
the  bougie  will  be  elevated  to  the  level  of  the  opening  into  the  esoph- 
agus (Fig.  471).  The  depth  of  the  diverticulum  may  be  readily 
determined  by  the  distance  the  bougie  is  elevated  when  the  thread  is 
made  taut. 


ESOPHAGOSCOPY  445 

The  bougie  should  always  be  examined  after  its  withdrawal  for 
the  presence  of  blood  or  pus  which  may  be  found  adhering  to  its  sur- 
face or  tip.  With  the  hollow  bougie  provided  with  a  lateral  opening 
near  its  tip,  fragments  of  tissue  sufficiently  large  for  examination  may 
be  brought  away  by  the  instrument,  which  when  placed  under  the 
microscope  may  confirm  a  diagnosis  of  possible  malignancy. 

ESOPHAGOSCOPY 

Esophagoscopy,  a  method  devised  by  Mikulicz,  consists  in  direct 
inspection  of  the  interior  of  the  esophagus  by  the  aid  of  a  long  endo- 
scopic tube  illuminated  by  electricity.  By  the  use  of  the  esophago- 
scope  in  the  hands  of  an  expert,  much  valuable  information  may  be 
obtained;  foreign  bodies  may  be  located  and  removed;  ulcers,  new 
growths,  strictures,  the  openings  of  diverticula,  etc.,  may  be  directly 
inspected;  and  fragments  of  tissue  may  be  removed  for  examination. 
Still,  the  discomfort  of  such  an  examination  for  the  patient  and  the 
experience  and  skill  required  in  the  use  of  the  instrument  on  the  part 
of  the  examiner  will  not  allow  it  to  supplant  the  ordinary  methods  of 
examination  as  a  routine. 

In  the  passage  of  the  esophagoscope  the  same  care  should  be 
observed  as  in  the  passage  of  any  esophageal  instruments.  The 
contraindications  to  its  use  are  practically  the  same  as  those  men- 
tioned for  the  sound  or  bougie,  viz.,  aortic  aneurysm,  recent  hem- 
orrhage from  the  esophagus,  advanced  pulmonary  or  cardiac  dis- 
ease, etc. 

Instruments. — Von  Mikulicz's  instruments  (Fig.  472)  are  cylin- 
drical tubes  about  2/5  to  1/2  inch  (10  to  13  mm.)  in  diameter,  bev- 
elled at  the  end  and  supplied  with  an  obturator  to  aid  in  their  intro- 
duction. On  the  outside,  the  tubes  are  marked  off  in  a  centimetric 
scale.  They  are  made  in  different  lengths,  according  to  the  depth  to 
which  it  is  wished  to  pass  the  instrument.  The  illumination  is  sup- 
plied by  a  panelectroscope  at  the  proximal  end  of  the  instrument. 
Among  other  instruments  of  this  type  may  be  mentioned  those  of 
Killian  and  Briinings. 

Other  tubes,  such  as  Jackson's  (Fig.  473)  or  Einhorn's,  for 
instance,  are  provided  with  illumination  at  the  distal  end  of  the 
instrument.  These  will  be  found  easier  to  manage,  as  with  the  former 
it  is  difficult  to  direct  the  Hght  properly  on  account  of  the  length  of 
the  tube.  To  examine  the  entire  length  of  the  esophagus,  Jackson 
uses,  for  adults,  a  tube  about  21  inches  (53  cm.)  long  and  2/5  inch  (10 


446 


THE   ESOPHAGUS 


mm.)  thick,  and  for  children,  a  tube  i8  inches  (45  cm.)  long  and  7/25 
inch  (7  mm.)  thick.  In  addition  to  the  esophagoscope,  a  Sajous 
applicator,  swabs  on  holders,  various  shaped  forceps  for  removing 


Fig.  472. — Von  Mikulicz  set  of  instruments  for  esophagoscopy.      (Gottstein  in 

Keen's  Surgery.) 

foreign  bodies  or  sections  of  tissues  for  examination,  etc.,  are  required. 
Asepsis. — The  tubes  and  accessory  instruments  may  be  sterilized 
by  boiling  and  the  lights  by  immersion  in  alcohol. 


Fig.  473. — Jackson's  esophagoscope. 

Preparation  of  Patient. — The  patient's  stomach  should  be  empty, 
to  avoid  regurgitation  of  its  contents.  Where  there  is  a  marked 
dilatation  of  the  esophagus,  a  preliminary  lavage  (see  page  449)  may 


ESOPHAGOSCOPY 


447 


be  necessary.  The  clothing  should  be  loosened  from  about  the 
patient's  neck  and  chest  and  any  plates  or  artificial  teeth  should  be 
removed  from  the  mouth. 

Position  of  Patient. — Some  operators  perform  esophagoscopy 
with  the  patient  sitting  up;  others,  with  the  patient  on  a  table  in  a 
right  lateral  position,  with  the  head  supported  and  controlled  by  an 
assistant.  This  latter  posture,  or  that  known  as  Rose's  posture, 
viz.,  the  patient  recumbent  with  the  head  hanging  over  the  end  of  a 
table,  supported  by  an  assistant,  who  raises,  lowers,  or  turns  the  head 
at  will  (Fig.  474),  is  preferable. 


Fig.  474. — The  position  of  the  patient  and  assistant  for  esophagoscopy. 
(After  Jackson.) 

Anesthesia. — General  anesthesia  may  be  required  in  children. 
For  adults,  painting  the  pharynx,  larynx,  and  entrance  of  the  esopha- 
gus with  a  10  per  cent,  solution  of  cocain  by  means  of  a  cotton  swab 
held  in  a  Sajous  appHcator  some  minutes  before  the  introduction  of 
the  tube  will  suffice.  This  may  be  very  effectually  done  through  a 
short  split-tube  spatula,  such  as  is  used  in  direct  laryngoscopy  (see 
page  398). 

Technic. — The  seat  of  trouble  should  have  been  previously  deter- 
mined by  means  of  a  bougie,  and  if  the  operator  possesses  tubes  of 
different  lengths  this  will  enable  him  to  select  one  of  the  proper  length. 


448 


THE   ESOPHAGUS 


The  tube  is  lubricated,  the  patient's  mouth  is  well  opened,  and,  with 
the  index-finger  of  the  left  hand,  the  base  of  the  tongue  is  drawn 


Fig.  475. — Shows  the  method  of  holding  the  esophagoscope.     (After  Jackson.) 

forward  (Fig.  476).     The  operator  then  introduces  the  tube,  with  the 
obturator  inserted  in  place,  backward  to  the  posterior  part  of  the 


Fig.  476. — First  step  in  esophagoscopy,  the  left  index-finger  guiding  the  in- 
strument into  the  esophagus.     (After  Jackson.) 

pharynx  and  then  downward,  the  assistant  at  the  same  time  extending 
the  patient's  head  so  as  to  bring  the  mouth  and  esophagus  nearly 


Fig.  477. — Shows  the  esophagoscope  in  place. 

in  the  same  straight  line.     The  patient  is  directed  to  aid  the  passage 
of  the  tube  by  swallowing.     As  soon  as  the  esophagus  has  been  well 


LAVAGE  OF  THE  ESOPHAGUS  449 

entered,  the  obturator  is  removed,  the  illumination  is  turned  on,  and 
the  tube  is  gently  pushed  on  into  the  canal  by  direct  sight,  the  sur- 
geon standing  or  being  seated  at  the  head  of  the  table  (Fig.  477). 
Under  direct  inspection  the  direction  of  the  esophagus  can  be  dis- 
tinguished and  the  tube  advanced  accordingly,  care  being  taken  to 
avoid  compression  of  the  trachea  by  a  faulty  direction  of  the  end  of 
the  tube.  In  the  cervical  portion,  the  walls  of  the  esophagus  lie  in 
apposition,  the  canal  being  represented  by  a  slit  extending  from  side 
to  side.  Below  the  level  of  the  sternum  the  canal  is  open.  The 
appearance  of  the  esophageal  mucous  membrane  differs  from  that  of 
the  trachea  in  that  it  has  not  the  deep  red  tint  of  the  latter,  but 
appears  pale  red  or  slightly  pink.  Any  mucus  or  regurgitated  matter 
from  the  stomach  that  blocks  the  end  of  the  tube  may  be  removed  by 
means  of  swabs  upon  long  applicators  or  by  the  aspirating  apparatus 
with  which  some  of  the  tubes  are  supplied.  In  this  manner  the  whole 
interior  of  the  canal  down  to  the  cardia  may  be  minutely  inspected, 
and  diseased  areas  treated  by  local  applications  if  desired.  Following 
the  operation,  if  there  is  pain  or  difficulty  in  swallowing,  cracked  ice 
in  small  quantities  mav  be  administered. 

SKIAGRAPHY 

The  X-rays  are  useful  in  locating  bones,  coins,  and  other  imper- 
vious foreign  bodies.  By  having  the  patient  first  swallow  bismuth  or 
similar  metallic  substances,  which  offer  resistance  to  the  penetration 
of  the  X-rays  and  are  capable  of  casting  a  shadow,  the  size,  shape, 
and  course  of  the  esophagus  may  be  outlined,  and  the  presence  of  a 
diverticulum,  constrictions,  or  dilatations  readily  recognized.  For 
this  purpose  a  mixture  of  bismuth  subcarbonate,  one  part,  to  two  of 
mucilage  of  acacia,  milk,  or  gruel  is  employed.  The  bismuth  forms 
a  coating  in  the  gullet  and  the  outline  of  the  tube  is  thus  represented 
upon  the  skiagraph  by  a  dark  shadow. 

Therapeutic  Measures 

LAVAGE  OF  THE  ESOPHAGUS 

Lavage  of  the  esophagus  is  employed  chiefly  for  the  purpose  of 
removing  collections  of  mucus  and  stagnated  or  decomposing  food 
particles  which  have  become  arrested  in  a  diverticulum  sac  or  in  a 
dilated  area  above  a  stenosis.     In  cancer  of  the  esophagus  it  is  fre- 

29 


45° 


THE   ESOPHAGUS 


Fig.  478. — Apparatus  for  esophageal  lavage. 
a,  Fenestra  in  the  tip  of  the  tube;  b,  glass  funnel;  c,  mark  to   indicate  the  dis- 
tance from  the  teeth  to  the  stomach. 


Fig.  479. — Boas'  apparatus  for  esophageal  lavage.     (After  Gumprecht.) 


DILATATION    OF    ESOPHAGEAL    STRICTURES   BY   BOUGIES  45 1 

quently  employed  to  remove  foul  and  decomposed  products  of  the 
ulceration,  and  gives  much  relief  to  the  patient. 

Apparatus. — An  ordinary  stomach-tube,  about  a  No.  20  American 
in  size  and  30  inches  (75  cm.)  long,  provided  with  two  lateral  windows 
near  the  tip,  and  fitted  with  a  small  glass  funnel  at  its  proximal  end, 
forms  the  necessary  apparatus  (Fig.  478).  More  elaborate  apparatus 
has  been  devised  for  esophageal  lavage,  such  as,  for  example,  Boas* 
tube  (Fig.  479),  which  is  provided  with  an  inflatable  rubber  balloon 
for  closing  the  lower  end  of  the  esophagus,  thus  preventing  solution 
passing  the  cardia;  but  the  simple  apparatus  described  above  will 
answer  in  the  majority  of  cases. 

Asepsis. — The  tube  and  funnel  should  be  sterilized  by  boiling 
before  use. 

Solution. — For  simple  lavage  sterile  water  is  sufficient.  Solutions 
with  an  antiseptic  or  astringent  action  are  also  sometimes  employed. 

Temperature. — The  solution  should  be  introduced  warm,  i.e.,  at 
a  temperature  of  about  100°  F.  (38°  C). 

Frequency .^ — In  some  cases  the  lavage  will  be  required  as  fre- 
quently as  every  day;  in  other  cases  once  every  other  day  is  sufficient. 
It  should  preferably  be  performed  before  the  first  meal  of  the  day. 

Position  of  the  Patient.— The  patient  should  sit  in  a  chair,  or 
else  should  sit  up  in  bed  with  the  head  thrown  back  and  the  chin 
elevated.     The  operator  stands  in  front. 

Technic. — The  patient  is  protected  by  a  sheet  or  a  towel  fastened 
about  his  neck,  and  is  given  a  basin  to  hold  for  the  purpose  of  receiv- 
ing any  vomitus  that  may  be  expelled  during  the  passage  of  the 
tube.  He  then  opens  his  mouth  widely,  and  the  operator  slowly 
inserts  the  stomach-tube,  moistened  with  water  down  to  the  seat  of 
the  dilatation,  being  careful  at  first  to  keep  the  tip  of  the  instrument 
close  to  the  posterior  wall  of  the  pharynx  to  prevent  its  entering 
the  larynx.  The  funnel  end  is  then  raised  and  through  it  from  2  to 
2  1/2  ounces  (60  to  75  c.c.)  of  warm  water  are  poured  into  the 
esophagus.  The  funnel  end  is  then  lowered  and  the  contents  are 
drained  off.  By  alternately  pouring  in  solution  and  draining  it  off, 
the  esophagus  may  be  thoroughly  cleansed  and  all  particles  of  food 
or  mucus  removed. 

THE  DILATATION  OF  ESOPHAGEAL  STRICTURES  BY 

BOUGIES 

The  treatment  of  an  esophageal  stricture  comprises  dilatation 
by  means  of  bougies,  internal  esophagotomy,  external  esophagotomy, 


452 


THE   ESOPHAGUS 


and,  when  the  stricture  is  impassable,  gastrostomy.  Gradual  dila- 
tation by  the  bougies  is  most  frequently  employed  and,  generally 
speaking,  is  the  best  form  of  treatment,  as  by  this  means  the  majority 
of  strictures  may  be  in  time  dilated.  The  tendency,  however,  is  for 
the  stricture  to  reform  after  dilatation  unless  a  bougie  be  passed  at 
intervals  during  the  remainder  of  the  patient's  life.  When  the 
stricture  involves  the  greater  part  of  the  canal,  dilatation  is  frequently 


/ 


Fig.  480. — The  most  frequent  seats  of  stricture  of  the  esophagus.  (Eisendrath.) 
A,  Aorta,  D,  Diaphragm,  i,  Stenosis  from  carcinoma  of  lower  end  of  the 
pharynx  and  beginning  of  the  esophagus;  2,  stenosis  from  pressure  of  tumors  of 
the  neck;  3,  stenosis  due  to  aneurysm  of  the  arch  of  the  aorta;  4,  stenosis  as  the 
result  of  caustic  or  lye  burns;  5,  stenosis  as  result  of  carcinoma  of  lower  end  of 
the  esophagus  and  cardiac  end  of  stomach. 


unsuccessful.  Dilatation  is  contraindicated  in  very  recent  burns  of 
the  esophagus.  Moderate  and  carefully  performed  dilatation,  how- 
ever, is  not  contraindicated  by  carcinoma. 

Strictures  may  be  located  in  any  part  of  the  esophagus,  but  the 
majority  are  situated  near  the  points  of  normal  constriction  of  the 


DILATATION    OF    ESOPHAGEAL    STRICTURES   BY  BOUGIES  453 

canal  (Fig.  480).  They  are  usually  single,  but  may  be  multiple, 
and  they  also  vary  in  form  and  shape,  being  valve-like,  annular, 
semicircular,  or  tortuous.  The  portion  of  the  canal  immediately 
above  a  tight  stricture  dilates  from  the  accumulation  of  food;  espe- 
cially is  this  the  case  if  the  stricture  is  low  in  the  canal,  and  as  a 
result  inflammation  or  suppuration  may  develop.     In  such  cases 


Fig.  481 — Cylindrical   esophageal  bougie. 

there  is  great  danger  of  perforating  the  walls  of  the  esophagus  unless 
extreme  gentleness  in  manipulation  is  observed. 

The  danger  of  passing  a  bougie  through  an  aneurysmal  sac  should 
also  be  kept  in  mind,  and  to  avoid  such  an  accident  a  careful  phys- 
ical examination  should  be  made  in  every  case  before  inserting  any 


Fig.  482. — Conical  esophageal  bougie. 

esophageal  instrument.  By  such  examination  the  discovery  of  other 
growths  within  the  neck  or  mediastinum  producing  compression  is 
often  possible.  It  is  next  necessary  to  determine  by  means  of  a 
bougie  the  location,  the  degree,  the  approximate  length,  and,  if 
possible,  the  character  of  the  stricture  before  any  attempts  at  dilata- 
tion are  made. 


Fig.  483. — Bulbous  esophageal  bougie. 

Instruments. — Flexible  bougies  of  woven  material  impregnated 
with  elastic  gum,  which  become  soft  when  placed  in  warm  water  and 
rigid  when  placed  in  cold  water,  are  generally  employed.  The 
bougies  vary  in  size  from  1/12  to  3/5  inch  (2  to  14  mm.).  In  a  nor- 
mal esophagus,  a  bougie  1/2  to  3/5  inch  (13  to  14  mm.)  in  diameter 
will  pass  the  narrow  portions  without  difficulty. 


454  THE    ESOPHAGUS 

For  strictures  of  fair  size,  say  the  size  of  a  lead  pencil,  cylindrical 
bougies  (Fig.  481)  may  be  employed;  for  smaller  strictures  the  con- 
ical (Fig.  482)  or  bulbous  instruments  (Fig.  483)  are  used. 

In  the  dilatation  of  very  tight  strictures  catgut  strings,  flexible 
whalebone,  or  linen  filiforms  similar  to  the  urethral  filiforms 
are  sometimes  employed.  They  are  inserted  by  the  aid  of  the 
esophagoscope  or  through  a  special  hollow  sound. 

Other  more  complicated  instruments  are  sometimes  used,  such 
as  Schreiber's  and  Billroth's  sounds.  The  former  (Fig.  484)  consists 
of  a  hollow  bougie  with  a  rubber  bag  on  the  dilating  end,  which  is 
capable  of  being  distended  with  fluid  forced  in  through  the  distal 
end  of  the  instrument.  Billroth's  sound  consists  of  a  cloth  sound 
filled  with  mercury.  These  instruments,  however,  possess  no  ad- 
vantages over  the  ordinary  flexible  bougie. 


^^~ 


Fig.  484. — Schreiber's  esophageal  sound.     (Gottstein  in  Keen's  Surgery.) 

Asepsis. — The  gum-elastic  bougies  may  be  sterilized  in  formalin 
vapor  or  by  immersion  in  a  saturated  boracic  acid  solution. 

Preparation  of  Patient. — In  cases  of  marked  dilatation  of  the 
canal  above  the  stenosis  full  of  stagnant  food  and  mucus,  prelimi- 
nary esophageal  lavage  (page  449)  is  indicated. 

Rapidity  of  Dilatation. — The  stretching  should  be  done  gradually. 
Rapid  dilatation  or  divulsion  is  dangerous  and  inadvisable. 

Frequency. — As  a  rule,  the  bougies  may  be  inserted  every  second 
or  third  day.  If  the  bougie  be  employed  too  frequently,  irritation 
at  the  seat  of  stricture  is  produced  and  the  condition  is  made  worse 
instead  of  improved.  After  full  dilatation  has  been  reached  the 
intervals  between  treatments  may  be  stretched  to  a  week,  and  then 
gradually  to  a  month.  The  patient  should  not  be  permitted  to  go 
longer  than  this,  however,  without  the  passage  of  a  bougie,  as  con- 
traction is  extremely  liable  to  develop.  At  any  signs  of  recurrence 
of  the  trouble,  more  frequent  treatments  are  necessary. 

Position  of  Patient. — The  patient  should  be  seated  in  a  chair  with 
the  head  thrown  well  back  and  with  the  chin  raised. 

Anesthesia. — Though  not  absolutely  necessary,  preliminary  co- 
cainization  of  the  pharynx  and  larynx  with  a  10  per  cent,  solution 
of  cocain  renders  the  operation  easier. 


DILATATION    OF    ESOPHAGEAL    STRICTURES   BY   BOUGIES         455 

Technic. — A  bougie  of  a  size  that  will  enter  the  stricture  is 
chosen.  This  is  determined  from  the  examination  of  the  stricture  pre- 
viously made.  The  bougie  is  softened  in  warm  water  and  bent  to  a 
gentle  curve  near  its  tip.  The  operator,  standing  in  front  of  the 
patient,  inserts  the  bougie  into  the  patient's  mouth  to  the  posterior 
wall  of  the  pharynx,  and,  keeping  it  close  to  this  latter  structure,  it 
is  slowly  advanced  into  the  esophagus  (see  Fig.  462).  If  difficulty 
is  encountered  in  entering  the  esophagus,  the  tongue  may  be  drawn 
forward  by  the  left  index-finger,  as  shown  in  Fig.  463. 


Fig.  485. — Von  Hacker's  method  of  introducing  thin  catgut  bougies.  (Gott- 
stein  in  Keen's  Surgery.)  a,  b,  c,  Into  the  stricture;  b' ,  through  a  wide  hollow 
bougie  {R). 

When  the  stricture  is  reached  care  must  be  taken  not  to  use  any 
force  in  attempting  to  pass  it,  as  a  false  passage  may  be  made  or  the 
instrument  may  simply  be  doubled  upon  itself.  By  gently  with- 
drawing and  then  advancing  the  instrument,  and  by  moving  its  tip 
in  different  directions,  the  opening  will  be  entered  if  the  particular 
instrument  is  of  sufficiently  small  caliber.  When  the  instrument  is 
once  within  the  stricture  the  operator  is  acquainted  with  the  fact 
by  the  tight  grasp  upon  the  bougie  exerted  by  the  stricture.  The 
bougie  should  be  slowly  passed  entirely  through  the  constriction,  and 
should  be  allowed  to  remain  in  place  from  five  to  ten  minutes  before 
it  is  withdrawn.     At  the  next  sitting  the  same  size  bougie  is  again 


456  THE    ESOPHAGUS 

inserted,  and,  if  the  stricture  seems  very  tight,  this  same  instniment 
may  be  passed  on  two  or  more  occasions  before  a  larger  one  is  em- 
ployed. When  there  is  more  than  one  stricture,  no  attempt  should 
be  made  to  dilate  the  lower  ones  until  dilatation  of  the  upper  is 
secured. 

Very  tight  strictures  may  be  dilated  by  means  of  a  thread  passed 
through  the  stricture,  over  which  as  a  guide  are  passed  small 
olivary  bougies  or  conical  sounds  (see  page  444) ;  by  means  of  fili- 
form bougies  inserted  through  an  esophagoscope,  or  by  von  Hacker's 
method  of  inserting  catgut  strings.  In  the  latter  procedure  a  hollow 
sound  made  especially  for  inserting  catgut  strands  is  passed  down 
as  far  as  the  face  of  the  stricture,  and  through  this  the  catgut  strands 
are  insinuated  into  the  opening  one  after  another  in  a  manner  simi- 
lar to  the  method  used  for  tight  urethral  strictures  (Fig.  485).  They 
are  left  in  place  fifteen  to  thirty  minutes,  and,  as  the  gut  swells,  the 
contracture  is  stretched.  As  soon  as  sufficient  dilatation  for  the 
passage  of  a  small  bougie  has  been  thus  produced,  bougies  of  a  con- 
ical shape  may  be  substituted. 

INTUBATION  OF  THE  ESOPHAGUS 

This  consists  in  the  insertion  of  a  tube  into  a  stenosed  esophagus 
which  is  left  in  place  continuously  for  varying  periods  at  a  time.  It 
is  a  method  of  treatment  used  in  cancer  of  the  esophagus  when  the 
patient  is  unable  to  swallow  food,  and  sometimes  as  a  means  of  dilat- 
ing elastic  strictures  which  are  dilatable,  but  rapidly  contract  after 
the  withdrawal  of  a  bougie. 

Long  tubes  inserted  into  the  stomach  through  the  mouth  or  nose 
or  short  tubes  which  can  be  passed  through  the  stenosed  area  by  the 
aid  of  a  guide  are  employed.  The  use  of  the  short  tubes  is  preferable 
and  is  far  more  agreeable  for  the  patient,  as  with  them  it  is  pos- 
sible for  the  patient  to  swallow  saliva  and  to  take  food  in  the  natural 
way,  the  ability  to  taste  food  being  also  preserved  by  the  patient. 
They  are,  however,  more  difficult  to  insert  than  are  the  long  tubes. 
Another  disadvantage  of  the  short  tube  is  that  if  it  becomes  blocked 
it  may  have  to  be  removed  for  cleansing.  If  the  obstruction  is 
situated  very  near  the  entrance  of  the  esophagus,  the  use  of  short 
tubes  is  usually  impracticable,  as  the  expanded  end  of  the  tube 
presses  on  the  larynx  and  produces  laryngeal  irritation  and  spasm. 
In  such  cases  long  tubes  are  indicated.  Long  tubes  are  also  indi- 
cated in  the  later  stages  of  carcinoma  of  the  esophagus,  with  a  fistu- 


INTUBATION  OF  THE  ESOPHAGUS  457 

lous  opening  between  the  esophagus  and  air-passages,  when  it  is 
necessary  to  prevent  any  food  from  passing  through  the  esophagus  in 
order  to  avoid  danger  of  lung  compKcations. 

Instruments. — When  long  tubes  are  indicated,  an  ordinary  hollow 
cylindrical  esophageal  tube  (see  Fig.  459)  or  a  rubber  stomach-tube 
of  appropriate  size  may  be  employed.  For  the  purpose-  of  feeding 
the  patient,  a  glass  funnel  that  will  fit  into  the  proximal  end  of  the 
tube  will  also  be  required. 


Fig.  486. — Symonds'  short  tube  for  intubation  of  the  esophagus. 

Short  tubes  of  gum  elastic  and  hard  rubber  have  been  devised 
by  Symonds,  von  Leyden,  and  others.  Symonds'  tubes  (Fig.  486) 
are  about  6  inches  (15  cm.)  long,  and  may  be  obtained  in  sizes  of 
varying  caliber.  The  lower  end  of  the  tube  has  a  terminal  or  a 
lateral  opening,  while  the  upper  extremity  ends  in  a  funnel-shaped 
expansion,  which  rests  upon  the  superior  surface  of  the  stricture  or 
growth  and  prevents  the  tube  from  slipping  down  the  esophagus;  to 
this  expanded  end  silk  threads  are  secured  as  shown  in  Fig.  486,  for 


Fig.  487. — Symonds'  tube  on  introducer. 

the  purpose  of  extracting  the  tube.     A  special  whalebone  guide  for 
inserting  the  tube  is  also  required  (Fig.  487). 

Asepsis. — Gum-elastic  instruments  are  sterilized  by  formalin 
vapor  or  by  immersion  in  a  saturated  solution  of  boracic  acid. 
Rubber  tubes,  however,  may  be  boiled.  Before  reinserting  the  same 
tube,  it  should  be  thoroughly  washed  with  soap  and  water  and 
resterilized. 


458 


THE   ESOPHAGUS 


Duration  of  the  Intubation. — For  dilating  a  stricture  the  tube  is 
left  in  place  twenty-four  to  forty-eight  hours,  and,  if  it  has  then  be- 
come loosened  through  stretching  of  the  contracture,  it  is  removed 
and  a  larger  one  is  inserted  and  allowed  to  remain  in  place  for  the 
same  length  of  time.  This  process  is  repeated  until  full  dilatation 
has  been  obtained. 

In  cancer  of  the  esophagus  the  tube  is  worn  continuously  except 
when  it  is  removed  once  every  ten  days  for  cleansing.  A  long  tube, 
however,  may  be  left  in  place  permanently,  as  it  can  be  kept  clean  by 
syringing  down  its  interior. 

Position  of  Patient. — The  patient  is  placed  in  the  same  position 
as  for  the  passage  of  any  esophageal  instrument,  viz.,  sitting  upright, 
the  head  thrown  well  back,  and  the  chin  elevated. 


Fig.  488. — Shows  long  esophageal  tube  passed  through  the  nose. 

Anesthesia. — As  an  aid  in  the  introduction  of  the  tube  the  phar. 
ynx  and  larynx  may  be  sprayed  with  a  10  per  cent,  solution  of  cocain. 

Technic. — i.  Long  Tubes. — The  site  of  the  stenosis  is  previously 
determined  by  means  of  a  bougie,  and  a  tube  that  will  comfortably 
pass  is  selected.  The  patient  widely  opens  his  mouth  and  the  opera- 
tor gently  inserts  the  tube  in  the  manner  already  described  for  the 
passage  of  an  esophageal  bougie  (page  440).  The  tube  is  passed  into 
the  stomach,  and  the  proximal  end,  which  is  brought  out  of  a  corner  of 
the  mouth,  is  fitted  with  a  cork  and  is  secured  to  the  ear  by  a  piece 
of  silk.  It  will  be  necessary  for  the  patient  to  remain  in  a  recum- 
bent position  with  the  head  to  one  side  to  allow  saliva  which  collects 
to  escape,  as  this  is  prevented  from  passing  down  the  canal. 

Instead  of  passing  the  tube  through  the  mouth  it  may  be  in- 


INTUBATIOX    OF    THE    ESOPHAGUS 


459 


serted  through  the  nostril  (Fig.  488),  a  method  that  will  be  far  more 
agreeable  to  the  patient.  The  free  end,  corked  as  above,  is  then  se- 
cured in  place  by  means  of  adhesive  plaster. 

2.  Short  Tubes. — A  tube  of  the  proper  size  is  selected  and  placed 
upon  the  introducer,  being  prevented  from  falling  off  by  the  silk 
threads  which  are  grasped  by  the  operator  with  the  same  hand  he 
employs  in  introducing  the  tube.  The  patient's  tongue  is  then  drawn 
well  forward  and  the  tube  is  passed  down  the  esophagus  and  is  in- 
serted through  the  stricture  by  means  of  the  introducer,  following  the 


Fig.  489. — Showing  the  method  of  introducing  Symonds'  short  tube. 


same  steps  as  for  the  passage  of  a  bougie  (Fig.  489).  When  the  tube 
is  in  proper  position  the  tension  on  the  threads  is  relaxed  and  the 
introducer  is  gently  disengaged  from  the  tube  and  removed.  The 
threads  are  then  brought  out  of  a  corner  of  the  mouth  and  are  secured 
to  the  ear  or  face  with  adhesive  plaster.  If  any  of  the  patient's 
teeth  are  missing  the  threads  should  be  made  to  emerge  from  the 
mouth  through  such  a  space  so  as  to  avoid  being  cut  by  the  teeth. 

Should  the  tube  become  blocked,  it  may  be  possible  to  remove 
the  obstruction  by  passing  a  very  small  bougie  down  through  it; 
otherwise  the  tube  will  have  to  be  removed  and  cleaned.  With- 
drawal of  the  tube  is  effected  by  making  gentle  traction  upon  the 
threads  secured  to  its  proximal  end. 


4  (jo 


THE    ESOPHAGUS 


Feeding. — While  the  tube  is  in  place  the  patient  is  kept  upon  a 
fluid  diet,  such  as  milk,  broth,  eggs  beaten  in  milk,  etc.  With  the 
short  tubes  food  may  be  administered  by  mouth,  but  when  the  long 
tubes  are  employed  the  nourishment  is  introduced  through  a  funnel 
inserted  in  the  proximal  end  of  the  tube.  Between  feedings  the  end 
of  the  tube  may  be  closed  by  means  of  a  cork. 


CHAPTER  XVH 
THE  STOMACH 

A natomic  Considerations 

The  stomach  may  be  described  as  a  hollow,  inverted,  pear-shaped 
organ,  the  greater  part  of  which  hes  in  the  epigastric  and  left  hypo- 
chondriac regions,  about  one-sixth  of  the  organ  extending  beyond  the 
right  of  the  median  line.  When  empty  it  lies  deep  in  the  abdomen 
in  front  of  the  pancreas,  being  covered  by  the  liver  and  diaphragm 


Fig.  490. — The  normal  position  of  the  stomach. 

for  about  two-thirds  of  its  area  and  by  the  abdominal  wall  over  the 
remaining  one-third.  The  space  in  which  the  stomach  comes  in 
contact  with  the  anterior  abdominal  w^all  is  triangular  in  shape, 
bounded  on  the  right  by  the  lower  border  of  the  liver,  on  the  left 
by  the  eighth,  ninth,  and  tenth  costal  cartilages,  and  below  by  the 
transverse  colon. 

The  upper  limit  of  the  stomach,  the  fundus,  reaches  the  level  of 
the  lower  border  of  the  fifth  rib  in  the  mammary  line,  being  in  rela- 
tion with  the  diaphragm  above  and  the  concave  surface  of  the  spleen 

461 


462  THE    STOMACH 

to  the  left.  The  lower  limit  or  greater  curvature  extends  to  the  level 
of  a  line  connecting  the  lowest  portions  of  the  ninth  or  tenth  ribs  or 
to  within  2  inches  (5  cm.)  of  the  umbilicus.  In  contraction  or  dila- 
tation of  the  organ,  however,  this  normal  position  of  the  greater  curva- 
ture may  be  modified  to  a  marked  degree.  The  cardiac  or  superior 
opening  lies  about  1/2  inch  (i  cm.)  to  the  left  of  the  median  line,  at 
the  level  of  the  eleventh  dorsal  vertebra,  or  anteriorly  at  the  level  of 
the  junction  of  the  sternum  and  seventh  costal  cartilage.  It  is 
situated  about  4  1/2  inches  (11  cm.)  posterior  to  the  anterior  abdom- 
inal wall.  The  pyloric  opening  is  situated  in  front  of.  but  on  a  lower 
plane  than,  the  cardiac  opening,  lying  to  the  right  of  the  median  line 
and  covered  by  the  right  lobe  of  the  liver.  It  is  on  a  level  with  the 
upper  border  of  the  body  of  the  first  lumbar  vertebra  or  anteriorly 
on  a  level  with  a  point  2  or  3  inches  (5  to  7.5  cm.)  below  the  sternoxi- 
phoid  joint.  The  long  axis  of  the  undistended  stomach  lies  in  more 
of  a  vertical  than  a  horizontal  plane  with  the  lesser  curvature  directed 
principally  to  the  right  and  the  greater  curvature  to  the  left.  When 
distended,  however,  the  organ  changes  its  position  somewhat;  the 
greater  curvature  is  tilted  to  the  front  so  that  the  upper  surface 
looks  upward  and  the  lower  dow^nward;  at  the  same  time  the  pylorus 
moves  2  inches  (5  cm.)  or  more  to  the  right. 

The  capacity  of  the  stomach  is  subject  to  wide  variations.  The 
average  is  about  2  1/2  pints  (1200  c.c).  When  the  stomach  is 
empty,  the  longest  diameter  measures  7  1/4  to  8  inches  (18  to  20 
cm.)  and  the  transverse  diameter  2  3/4  to  3  1/4  inches  (7  to  8  cm.). 
When  the  organ  is  filled,  the  longest  diameter  is  increased  to  10  or  12 
inches  (25  or  30  cm.)  and  the  widest  point  of  the  transverse  diameter 
to  3  1/4  or  4  inches  (8  or  10  cm.). 

Diagnostic  Methods 

In  the  diagnosis  of  stomach  diseases  a  history  of  the  previous  and 
the  present  condition  of  the  patient  should  be  carefully  taken  and  a 
general  physical  examination  should  be  made  before  the  examination 
of  the  stomach  itself  is  undertaken.  In  obtaining  the  patient's 
history,  in  addition  to  the  usual  questions  common  to  all  histories, 
inquiry  should  be  directed  especially  to  the  following  points:  the 
general  condition  of  the  health,  the  appetite,  any  loss  of  weight,  the 
date  and  manner  of  onset  of  the  symptoms,  pain,  sensation  of  pressure 
or  distention,  nausea,  vomiting,  vomiting  of  blood,  etc.  Of  special 
diagnostic  importance  is  a  history  of  gastric  pain,  vomiting,  or  the 
vomiting  of  blood. 


DIAGNOSTIC   METHODS  463 

As  to  pain,  one  should  ascertain  its  character,  its  location,  whether 
diffuse  or  circumscribed  in  area,  and  especially  the  time  of  its  onset 
in  relation  to  the  taking  of  food  and  the  length  of  time  it  persists 
after  meals,  A  simple  feeling  of  pressure  or  fulness,  however,  should 
not  be  confounded  with  pain.  Patients  often  confuse  the  two.  It 
is  also  important  to  determine  whether  the  pain  is  present  at  all 
times  or  only  at  certain  stated  periods  and  whether  any  special  variety 
of  food  has  an  influence.  Pain  complained  of  when  the  stomach  is 
empty  is  probably  due  to  hyperchlorhydria,  in  which  case  it  is  re- 
lieved by  eating.  On  the  other  hand,  the  pain  of  an  ulcer  or  cancer 
comes  on  after  eating,  and  the  seat  of  pain  is  usually  localized.  In 
ulcer  it  is  severe,  comes  on  soon  after  eating,  and  is  often  completely 
relieved  by  vomiting.  Its  origin  is  often  located  by  the  patient  in  the 
back  in  the  region  of  the  lower  dorsal  vertebra  on  the  left  side.  In 
cancer  the  pain  is  not,  as  a  rule,  so  severe  as  that  of  ulcer  nor  does 
it  come  on  so  soon  after  eating,  and  it  is  not  so  uniformly  relieved 
by  vomiting. 

With  a  history  of  nausea  and  vomiting,  the  examiner  should  in- 
quire into  the  relation  of  these  symptoms  to  the  taking  of  food,  the 
frequency  of  occurrence,  the  character  and  the  quantity  of  vomitus^ 
and  whether  the  patient  is  relieved  by  vomiting.  This  all  has  an  im- 
portant bearing  upon  the  case.  Nausea,  as  a  rule,  but  not  always, 
precedes  vomiting.  In  certain  conditions,  especially  when  of  nervous 
origin,  nausea  may  be  present  when  the  stomach  is  empty.  The 
time  of  vomiting  is  also  quite  important.  In  gastric  ulcer  the  vomit- 
ing usually  takes  place  soon  after  feeding,  that  is,  within  an  hour  or 
so;  and,  as  already  pointed  out,  its  occurrence  usuaUy  reheves  the 
pain  complained  of.  In  cancer  of  the  stomach,  vomiting  may  not 
appear  until  late  in  the  disease  and,  as  a  rule,  the  attacks  of  vomiting 
do  not  come  on  at  such  short  intervals  after  feeding  as  in  the  case  of 
ulcer.  In  dilatation,  on  the  other  hand,  vomiting  occurs  at  com- 
paratively long  intervals,  and  the  amount  brought  up  is  correspond- 
ingly large.  Blood  in  the  vomitus  is  always  of  diagnostic  importance. 
A  profuse  hemorrhage  from  the  stomach  generally  signifies  an  ulcer, 
while  the  constant  vomiting  of  blood-streaked  material  points  more 
toward  cancer;  especially  is  this  true  if  the  vomited  matter  has  a 
foul  odor. 

It  has  been  possible  here  to  point  out  the  importance  and  the 
significance  of  but  a  few  symptoms,  and  for  farther  details  the  reader 
is  referred  to  works  on  diagnosis  where  these  will  be  found  fully 
discussed.     The  writer  simply  wishes  to  emphasize  the  importance 


464  THE    STOMACH 

of  a  careful  history  and  to  point  out  in  a  general  way  the  lines  of 
questioning. 

A  general  physical  examination  should  never  be  neglected,  even 
though  the  patient  refers  his  symptoms  to  the  stomach  alone,  for 
secondary  disturbances  of  the  functions  of  the  stomach  are  present 
in  a  great  variety  of  diseases.  This  examination  should  include  the 
mouth,  the  tongue,  the  chest,  the  abdomen,  an  analysis  of  the  urine, 
an  examination  of  the  blood,  etc.  When  all  possible  information  has 
been  obtained  from  these  sources,  a  special  examination  of  the 
stomach  itself  should  be  made,  for  which  the  following  methods  are 
available:  (i)  inspection;  (2)  palpation;  (3)  percussion;  (4)  ausculta- 
tion; (5)  inflation;  (6)  examination  of  the  gastric  secretion;  (7)  tests 
for  determining  the  motor  and  absorptive  power  of  the  stomach;  (8) 
transillumination;  (9)  gastroscopy;  and  (10)  skiagraphy. 

INSPECTION 

Abdominal  inspection  in  thin  individuals  may  at  times  give 
valuable  information,  but  in  stout  persons  the  method  is  of  very 
limited  value.  In  favorable  cases  it  may  be  possible  by  this  means 
to  determine  the  size  and  position  of  the  stomach  by  tracing  the 
shadow  which  represents  the  outline  of  the  greater  curvature.  In- 
spection is  greatly  aided  by  a  preliminary  inflation  of  the  organ  (page 
471).  When  thus  distended  the  stomach  becomes  separated  from  the 
surrounding  organs  and  its  contour  is  more  easily  made  out.  At  the 
same  tinie  abnormal  positions  or  new  growths  may  be  better 
recognized. 

Position  of  Patient. — The  patient  is  placed  upon  a  firm  flat  table, 
with  his  head  directed  toward  the  source  of  light,  so  that  the  rays  will 
fall  from  the  head  toward  the  feet.  The  light  should  be  so  regulated 
by  adjustment  of  the  window  shades  that  it  enters  on  a  plane  only  a 
little  above  the  patient. 

Technic. — The  examiner  takes  his  stand  near  the  patient's  feet 
and,  by  moving  from  side  to  side,  is  enabled  to  make  out  the  stomach 
outlines  'from  the  shadows  cast  by  the  inequalities  of  the  abdominal 
wall  produced  by  the  stomach  beneath  (Fig.  491).  At  times  tumors 
of  the  body  of  the  stomach  or  of  the  pylorus  may  be  observed  elevat- 
ing the  abdominal  walls,  and,  if  the  growth  be  movable,  a  change  in 
its  position  may  be  noted  when  the  stomach  is  full  and  when  it  is 
empty.  If  there  be  obstruction  of  the  pylorus  with  dilatation  and 
hypertrophy  of  the  walls,  peristaltic  movements  of  the  stomach  may 


INSPECTION 


465 


be  observed  after  taking  food.  These  waves  may  be  seen  extending 
toward  the  pylorus  from  under  the  ribs  in  the  left  upper  quadrant  to 
the  right  lower  quadrant.     Peristalsis  may  be  excited  by  tapping  the 


Fig.  491. — Inspection  of  the  stomach. 


Fig.  492. — Showing  the    shape  of  :  (i)  A    dilated    stomach,    (2)    an  hour-glass 
stomach,  (3)  the  stomach  in  gastroptosis. 

abdomen  or  by  the  application  of  cold.  A  dilated  stomach  may  be 
determined  from  the  great  bulging  in  the  epigastrium  and  from  trac- 
ing the  greater  curvature  to  a  point  considerably  below  the  umbili- 

30 


466  THE    STOMACH 

cus,  and  at  times  an  hour-glass  contraction  may  be  recognized  (Fig. 
492).  In  gastroptosis  the  epigastrium  will  be  retracted,  and  the 
lesser  curvature  may  be  seen  represented  by  a  groove  extending  from 
the  umbilicus  to  the  ribs  upon  the  left  and  above.  Depression  of  the 
epigastrium  will  also  be  seen  in  stenosis  of  the  cardia. 

PALPATION 

Palpation  is  by  far  the  most  reliable  of  the  methods  of  physical 
examination.     The  stomach  should,  when  possible,  be  palpated  both 


Fig.  493. — Method  of  palpating  the  stomach. 

before  and  after  taking  food,  as  tumors  of  the  posterior  wall  are  often 
capable  of  being  felt  only  when  the  stomach  is  empty.  The  large 
intestine  should  be  emptied  by  an  enema,  if  necessary,  so  as  to  avoid 
mistaking  feces  for  new  growths.  The  examination  should  be  carried 
out  systematically,  and  of  course  it  must  not  be  limited  to  the  stom- 
ach alone,  but  all  the  other  abdominal  organs  should  be  palpated 
as  well. 

Position  of  Patient. — The  patient  lies  recumbent  with  the  abdom- 
inal muscles  as  relaxed  as  possible.  If  it  is  necessary  to  obtain  greater 
relaxation  than  is  possible  by  this  posture,  the  knees  should  be  drawn 
up  and  the  head  and  thorax  should  be  slightly  raised  upon  a  pillow. 
Where  there  is  considerable  rigidity  of  the  abdominal  muscles  or  in 


PALPATION 


467 


fat  individuals,  relaxation  may  be  secured  by  placing  the  patient  in  a 
warm  bath. 

Technic. — The  examination  should  be  performed  in  a  warm 
room  and  the  physician's  hands  should  be  warmed  to  avoid  the 
muscular  spasm  produced  by  cold  hands.  The  patient  is  instructed 
to  keep  his  mouth  open  and  to  breathe  regularly  and  deeply  to  induce 
the  fullest  amount  of  relaxation.  The  examiner  sits  or  stands 
beside  the  patient  and  places  both  hands  fiat  upon  the  abdomen,  with 
the  palms  down  and  the  fingers  slightly  flexed,  and  palpates  with  the 
finger-tips.     Only   gentle    manipulations    should   be    employed,    as 


Fig.  494. — Palpating  a  tumor  of  the  stomach  between  the  fingers  of  the  two  hands. 

otherwise  spasm  of  the  abdominal  muscles  will  be  induced  and  the 
aim  of  the  examiner  will  be  defeated. 

When  it  is  desired  to  perform  deep  palpation  for  the  recognition 
of  deep-seated  tumors,  one  hand  is  superimposed  upon  the  other, 
the  upper  hand  making  the  pressure  and  the  lower  one  performing  the 
palpation  (Fig.  493).  Deep  palpation  is  greatly  aided  by  having  the 
patient  breathe  deeply;  it  then  becomes  possible  for  the  palpating 
hand  to  follow  the  receding  abdominal  walls  with  expiration. 

In  palpating  tumors,  one  hand  is  used  to  fix  the  growth  and  the 
other  outlines  its  size  and  determines  its  consistency,  fixity,  or 
mobility,  and  the  presence  or  absence  of  pulsation,  tenderness  upon 
pressure,  etc.  (Fig.  494). 


468 


THE    STOMACH 


The  examiner  should  lirst  determine  the  size  and  position  of  the 
stomach.  Inflation  (page  471)  is  a  great  aid  to  palpation,  as  it  is 
usually  impossible  to  palpate  the  outline  of  an  empty  organ.  An- 
other method  of  determining  the  size  or  the  position  of  the  stomach 
is  by  means  of  a  long  soft-rubber  stomach-tube  passed  into  the  organ 
to  such  an  extent  that  it  lies  along  the  greater  curvature.  The 
greater  curvature  and  the  pylorus  may  thus  be  outlined  by  palpating 
the  tube  through  the  abdominal  walls.  All  parts  of  the  organ  are 
next  carefully  palpated  with  the  purpose  of  determining  the  presence 
or    absence  of  new  growths,  painful    spots,   etc.     Tumors    of    the 


^ite  tif  tenderness. 
It  ulcer  o^pylomS 

jSue  of  tenderness 
aieer  oft/u  duode/ra/n 


usual  sites  of 
tenderness  in- 
uleer  o^J  tomach , 


Fig.  495. — Points    of    pressure    tenderness    in    ulcer    of    the    stomach.     (Mayo 
Robson  in  Keen's  Surgery.) 

pylorus  and  the  greater  curvature  are  readily  palpable.  The  former 
are  usually  situated  to  the  right  of  the  median  line,  between  the 
xiphoid  and  the  umbilicus,  but  they  have  a  wide  range  of  motion 
unless  adherent.  Tumors  of  the  lesser  curvature  lie  to  the  left  of 
the  median  line,  thus  differentiating  them  from  those  of  the  gall- 
bladder. They  are  less  freely  movable  than  those  of  the  pylorus. 
Tumors  of  the  cardia  are  seldom  palpable.  Changing  the  position 
of  the  patient  to  a  lateral  one  is  often  of  service  in  rendering  a  growth 
more  accessible  to  the  examiner.  The  knee-chest  posture  is  also  of 
value,  as  deep-seated  movable  tumors  then  fall  forward  toward  the 
anterior  abdominal  wall. 

Eliciting  tender  spots  on  palpation  is  frequently  a  diagnostic  aid. 
In  organic  diseases,   such  as  ulcer,   cancer,  gastritis,  etc.,   pain  is 


PERCUSSION 


469 


spontaneous  and  is  increased  upon  pressure,  while  in  nervous  condi- 
tions it  is  generally  diminished  or  relieved  on  pressure.  In  gastritis 
and  nervous  affections  the  pain  is  diffuse,  while  in  ulcer  and  cancer 
it  is  usually  localized  to  a  small  circumscribed  area.  The  most 
common  points  of  tenderness  for  ulcer  are  between  the  left  costal 
margin  and  the  mid-line  ^Fig.  495) ;  points  of  pressure  tenderness  are 
also  at  times  found  i  to  2  inches  (2.5  to  5  cm.)  to  the  left  of  the  spine, 
in  the  neighborhood  of  the  twelfth  dorsal  vertebra  fFig.  496).  In 
affections  of  the  gall-bladder  similar  tender  points  will  be  frequently 
found  more  to  the  right  of  the  spinal  column. 


jSites  of  tendertte^f 
in  ulcer  of    — 
ike  eSTo/rraeJi 


Fig.  496. — Points    of    pressure   tenderness   found   posteriorly    in    ulcer    of    the 
stomach,     (.vlayo  Robson  in  Keen's  Surgery.) 


PERCUSSION 

Only  the  greater  curvature  and  the  portion  of  the  anterior  surface 
of  the  stomach  in  contact  with  the  anterior  abdominal  wall  are  access- 
ible for  percussion,  conseqaently  the  chief  use  of  this  method  is  to 
determine  the  shape  and  size  of  the  stomach.  Percussion  of  the 
stomach,  even  under  the  most  favorable  conditions,  is  unreliable,  on 
account  of  the  proximity  of  other  air- containing  organs.  The  chief 
soarce  of  error  is  the  resonance  of  the  transverse  colon,  which  may  be 
confused  mth  that  of  the  stomach.  To  avoid  this  the  stomach  may 
be  distended  with  gas  and  the  colon  with  fluid,  or  the  colon  may  be 
inflated  and  the  patient  may  drink  one  or  more  glasses  of  water.  In 
either  case  a  contrast  between  the  tympany  of  the  one  and  the  dulness 
of  the  other  wdll  be  obtained  on  percussion.     The  percussion  note 


470 


THE    STOMACH 


over  the  stomach  is  a  high-pitched  metallic  tympany,  but  it  will  vary 
much,  depending  upon  whether  the  stomach  is  empty,  whether  it  is 
full  of  food,  or  simply  contains  air.  Percussion  should  be  performed 
when  the  stomach  contains  some  air;  under  inflation  of  the  organ 
percussion  furnishes  even  more  valuable  results. 

Position  of  the  Patient. — The  patient  should  lie  in  the  recumbent 
posture. 

Technic. — The  palmar  surface  of  the  middle  finger  of  the  left  hand 
is  laid  upon  the  area  it  is  intended  to  percuss  and  is  held  firmly 


Fig.  497. — Percussion  of  the  stomach. 

against  the  surface,  while  with  the  flexed  middle  finger  of  the  right 
hand  a  number  of  sharp  taps  or  blows  are  struck  (Fig.  497).  The 
force  of  the  percussion  should,  as  a  rule,  be  very  light,  but,  if  it  is 
desired  to  make  out  a  deeply  placed  growth,  firm  heavy  percussion 
will  be  required.  The  same  is  true  when  the  abdominal  walls  are 
very  thick.  Having  outlined  the  stomach  with  the  patient  recum- 
bent, the  percussion  should  be  performed  with  the  patient  upright 
to  determine  if  the  organ  sinks  down  from  its  normal  position. 

AUSCULTATION 

By  listening  to  sounds  produced  within  the  esophagus  during  the 
swallowing  of  fluids  and  to  sounds  originating  within  the  stomach 


IXTLATIOX    OF    THE    STOIIACH  471 

itself,  certain  information  of  diagnostic  importance  may  be  obtained. 
By  the  first  method  it  is  possible  to  determine  whether  there  be  an 
obstruction  of  the  cardia  or  not.     It  is  carried  out  as  follows : 

The  operator  listens  with  his  stethoscope  placed  over  the  esopha- 
gus, that  is,  to  the  left  of  the  ensiform  cartilage  or  to  the  left  of  the 
spinal  column  opposite  the  ninth  or  tenth  dorsal  vertebra  while  the 
patient  is  swallowing  fluids.  Two  sounds  are  thus  heard:  first,  a 
spurting  sound  that  immediately  foUows  the  act  of  swaUowing.  and 
a  second  sound,  more  ratthng  in  character,  known  as  the  '■degluti- 
tion murmur.'"  which  is  heard  six  or  seven  seconds  (sometimes  as 
much  as  twelve  seconds)  later;  it  represents  the  passing  of  food 
through  the  cardiac  orifice  into  the  stomach.  If  this  second  sound 
is  constantly  absent,  more  or  less  complete  occlusion  of  the  cardia 
is  presumable. 

The  succussion  or  splashing  sounds  that  originate  in  the  stomach 
itself  are  of  greater  diagnostic  importance.  In  order  to  obtain  these 
sounds  the  stomach  must  contain  air  and  be  partly  filled  with  fluid. 
The  patient  lies  recumbent  and  the  operator  Hstens  with  his  ear  near 
the  abdomen  while  he  taps  the  abdominal  wall  in  the  region  of  the 
stomach  ^dth  his  finger-tips.  Succussion  sounds  may  also  be  ehcited 
by  mo\dng  the  patient  quickly  from  side  to  side.  These  sounds 
should  be  difl'erentiated  from  other  gurgling  sounds  which  are  heard 
when  the  stomach  contains  only  air  or  is  empty.  Succussion  in 
itseK  is  of  no  diagnostic  importance,  for  it  may  be  heard  in  a  normal 
stomach  containing  a  quantity  of  fluid.  It  is  pathological,  however, 
if  obtained  when  the  stomach  should  normally  he  empt\\  that  is,  in  the 
morning  before  breakfast,  three  hours  after  a  test  breakfast,  or  seven 
hours  after  a  test  dinner.  It  then  indicates  a  condition  of  atony 
or  deficient  motility.  When  succussion  is  heard  over  an  abnormally 
large  area,  or  beyond  the  normal  boundaries  of  the  organ,  it  indicates 
dilatation  or  gastroptosis.  The  outlines  of  the  stomach  may  be 
mapped  out  with  considerable  accuracy  by  tapping  first  from  above 
downward,  and  then  from  side  to  side,  the  examiner  listening  the 
while  with  a  stethoscope  placed  over  the  stomach  and  noting  where 
the  splashing  sounds  stop. 

INFLATION  OF  THE  STOMACH 

The  stomach  may  be  inflated  for  diagnostic  purposes  to  deter- 
mine its  size,  shape,  and  position,  and  to  establish  the  presence  or 
absence  of  tumors.  It  is  of  great  aid  to  inspection,  palpation,  or 
percussion. 


47-2  THE    STOMACH 

The  inflation  may  be  performed  by  means  of  efTervescent  solu- 
tions giving  off  carbonic  acid  gas  or  by  means  of  air  introduced 
into  the  stomach  through  a  tube.  Inflation  by  the  latter  method  is 
safer,  as  it  is  under  the  direct  control  of  the  operator  and  may  be 
stopped  at  any  moment  if  desired;  furthermore,  the  distention  may 
be  immediately  relieved  if  necessary.  On  the  other  hand,  distention 
by  means  of  carbonic  acid  gas  is  of  great  advantage  in  nervous  individ- 
uals who  fear  the  stomach-tube.  It  is  not  always  satisfactory,  how- 
ever, as  the  dosage  may  not  be  large  enough  to  generate  sufficient  gas 
in  a  capacious  stomach  or,  if  too  much  gas  is  formed,  it  may  produce 
pain  and  vomiting.  With  either  method  some  caution  must  be 
observed  and  the  inflation  mast  be  immediately  stopped  if  pain  be 
produced.  Inflation  is  contraindicated  in  recent  hemorrhage  of  the 
stomach,  in  suspected  gastric  ulcer,  in  advanced  cardiac  disease,  and 
in  advanced  arterial  disease. 

Under  distention  the  stomach  is  raised  from  the  neighboring 
organs  and  its  limits  thus  become  more  clearly  outlined,  so  that  condi- 
tions of  dilatation,  gastroptosis,  and  hour-glass  contractions  may  be 
distinguished  and  tamors  may  be  rendered  more  pronounced.  Be- 
fore performing  inflation  in  the  case  of  suspected  gastric  tumor,  the 
abdomen  should  be  carefully  examined  and  the  exact  situation  of  the 
growth  noted;  by  then  noting  the  position  of  the  growth  after  infla- 
tion it  may  be  determined  whether  the  growth  is  connected  with  the 
stomach  and  whether  it  is  fixed  by  adhesions  or  is  movable.  Fre- 
quently under  inflation  it  is  possible  to  determine  by  sight  and  by 
palpation  the  direct  continuity  between  the  stomach  and  the  tumor. 
Tumors  of  the  pylorus  and  of  the  anterior  stomach  wall  become  more 
prominent,  while  those  of  the  posterior  wall  become  less  so  when  the 
stomach  is  inflated.  Tumors  of  the  pylorus  generally  move  down- 
ward and  to  the  right  under  inflation.  Tumors  of  the  lesser  curva- 
ture near  the  cardia  are  displaced  to  the  right  under  the  liver.  At 
the  same  time  spurious  tumors  due  to  spasm  disappear. 

Apparatus. — For  inflation  with  carbonic  acid  gas  no  apparatus  is 
required.  A  stomach-tube  should  be  at  hand,  however,  for  the  pur- 
pose of  relieving  the  patient  of  distention  from  gas  if  necessary. 

To  inflate  with  air  an  ordinary  stomach-tube  30  inches  (75  cm.) 
long,  of  soft  rubber,  to  the  proximal  end  of  which  a  double  cautery 
bulb  or  a  Davidson  syringe  is  attached,  will  be  required  (Fig.  498). 

Asepsis. — The  tube  should  be  sterilized  by  boiling. 

Position  of  the  Patient. — If  desired,  the  tube  may  be  passed  with 
the  patient  sitting  up,  but  the  inflation  and  the  examination  should 


INFLATION    OF    THE    STOilACH 


473 


be  carried  out  with  the  patient  recumbent  and  with  the  chest  and 
abdomen  well  exposed  to  view. 

Technic. — i.  By  Carbonic  Acid  Gas. — The  patient  is  given  i 
dram  (4  gm.)  of  bicarbonate  of  soda  dissolved  in  3  ounces  (90  c.c.) 
of  water,  and  then  a  little  less  than  i  dram  (4  gm.)  of  tartaric  acid 
dissolved  in  3  ounces  (90  c.c.)  of  water.  As  the  two  solutions  come 
in  contact,  carbonic  acid  gas  is  generated  and  the  stomach  is  thereby 
distended.  In  dilatation  of  the  stomach,  however,  it  may  be  neces- 
sary to  give  a  second  dose  to  obtain  sufficient  distention  for  the  pur- 
pose of  mapping  out  the  outlines  of  the  organ. 


Fig.  498. — Stomach-tube  and  Davidson  sj^ringe  for  inflating  the  stomach. 


2.  By  Air. — To  inflate  a  stomach  successfully  with  air  through  a 
tube  it  is  essential  that  the  patient  be  accustomed  to  the  passage  of 
the  stomach-tube- — the  tube  should  certainly  have  been  passed  at 
least  once  previously.  The  tube  is  inserted  as  follows:  The  patient 
is  instructed  to  open  the  mouth,  and  the  tube,  moistened  with  water, 
is  passed  along  the  roof  of  the  mouth  to  the  pharynx.  From  this 
point  it  is  advanced  partly  by  swallowing  efl'orts  on  the  part  of  the 
patient  and  partly  by  the  operator  who  pushes  it  on  until  it  has 
passed  a  sufficient  distance  to  be  carried  beyond  the  cardia.  By 
alternately  compressing  and  relaxing  the  inflation  bulb  the  stomach  is 
then  gently  pumped  up  with  air  until  it  is  sufficiently  distended  for 
the  purposes  of  the  examination.  In  the  case  of  an  insufficiency  of 
the  pylorus  it  may  be  impossible  to  distend  the  stomach,  the  gas 
being  expelled  on  into  the  small  gut.     This  will  be  evidenced  by  a 


474  THE    STOMACH 

generalized  swelling  of  the  abdomen,  instead  of  a  distention  localized 
in  the  region  of  the  stomach. 

As  soon  as  the  examination  is  completed,  the  inflation  bulb  is 
removed  from  the  end  of  the  tube  and  the  air  is  allowed  to  escape 
so  as  to  avoid  the  disagreeable  distention.  The  abdomen  may  be. 
kneaded  to  facilitate  the  escape  of  the  air. 

EXTRACTION  OF  THE  STOMACH  CONTENTS 
FOR  EXAMINATION 

The  contents  of  the  stomach  may  be  removed  for  purposes  of 
diagnosis  when  it  is  desired  to  examine  the  gastric  secretion  chemic- 
ally and  to  test  the  motor  functions  of  the  stomach.  Such  examina- 
tion often  gives  results  of  value  both  diagnostically  and  prognosti- 
cally,  but,  while  gastric  analysis  is  of  great  importance,  the  results 
obtained  by  such  examination  must  not  be  relied  upon  to  the  exclusion 
of  other  methods  of  diagnosis,  as  they  are  by  no  means  final.  In  all 
cases  the  history  and  the  results  of  physical  examination  should  be 
given  due  consideration. 

To  test  the  digestive  power  of  the  stomach  it  is  necessary  to 
examine  the  contents  at  the  height  of  digestion.  In  other  cases,  as 
when  h}-persecretion  or  disturbance  of  the  motor  power  of  the 
stomach  is  suspected,  the  contents  of  the  fasting  stomach  should  be 
examined.  Normally,  the  stomach  should  be  empty  within  eight 
hours  after  a  full  meal,  and  if  empty  it  should  not  secrete  hydro- 
chloric acid.  If,  therefore,  the  contents  of  the  stomach,  removed  in 
the  morning  before  any  food  has  been  taken  since  the  evening  before, 
show  the  presence  of  food  or  if  a  considerable  quantity  of  fluid  con- 
taining free  hydrochloric  acid  is  obtained,  it  points  in  the  former 
case  to  motor  insufiiciency  and  in  the  latter  to  hypersecretion. 

Test  Meals. — To  obtain  results  from  which  comparisons  may  be 
drawn  the  patient  should  be  given  on  an  empty  stomach  a  meal  of  a 
definite  composition  and  the  contents  of  the  stomach  should  be  re- 
moved after  a  definite  lapse  of  time.  For  this  purpose  either  a  test 
breakfast  or  a  mid-day  test  dinner  is  employed. 

The  Ewald-Boas  test  breakfast  consists  of  one  or  two  rolls — be- 
tween I  and  2  ounces  (35  and  70  gm.),  a  cup  of  tea  without  sugar  or 
milk,  or  10  to  14  ounces  (300  to  400  c.c.)  of  water.  This  is  given 
upon  an  empty  stomach  in  the  morning  and  removed  in  one  hour. 

The  Riegel  test  dinner  consists  of  a  large  plate  of  meat  soup — 
about  14  ounces  (^400  c.c),  a  large  portion  of  beefsteak  or  other  meat, 


EXTRACTION  OF  THE  STOMACH  CONTENTS  475 

weighing  5  to  7  ounces  (150  to  200  c.c),  mashed  potatoes —  i  1/2 
ounces  (50  gm.),  and  a  roll — i  ounce  (35  gm.).  The  contents  of  the 
stomach  are  removed  and  examined  three  or  four  hours  later. 

Examination  of  the  Stomach  Contents. — The  object  of  a  gastric 
analysis  is  twofold:  First,  to  determine  the  presence  or  absence  of 
constituents  which  are  normally  present,  and,  second,  to  ascertain 
whether  other  substances  exist  which  should  normally  be  absent. 
Normally,  the  gastric  contents  one  hour  after  a  test  breakfast  con- 
sist of  from  I  to  2  1/3  ounces  (30  to  70  c.c.)  of  acid  material  which 
upon  filtration  yields  a  clear  yellow  or  yellowish-brown  fluid.  Upon 
analysis  this  contains  a  total  acidity  of  40  to  60  (0.15  to  0.21  per  cent.), 
free  hydrochloric  acid  25  to  50  (o.i  to  0.2  per  cent.),  pepsin,  rennin, 
albumoses,   peptones,   maltose,   achroodextrin,   and  erythrodextrin. 

The  technic  of  gastric  analysis  will  be  found  in  works  upon  clinical 
laboratory  methods.  Such  examinations,  however,  should  be  made 
along  the  following  lines : 

1.  Macroscopical  examination,  noting  the  quantity,  character, 
odor,  reaction,  etc. 

2.  Microscopical  examination. 

3.  Chemical  Examination. — This  should  include  tests  to  deter- 
mine the  presence  or  absence  of  free  hydrochloric  acid  and  of  com- 
bined hydrochloric  acid,  the  degree  of  total  acidity,  the  presence  of 
lactic  acid,  the  presence  of  volatile  acids,  the  products  of  digestion, 
the  presence  of  rennin  and  pepsin,  and  the  character  of  the  carbo- 
hydrates. 

The  Significance  of  Variations  in  the  Composition  of  the  Gastric 
Secretion. — Hyperchlorhydria. — Free  hydrochloric  acid  is  found  in 
excess  in  the  early  stages  of  chronic  gastritis,  in  gastric  neuroses,  in 
gastric  ulcer,  and  in  hypersecretion.  It  points  strongly  against 
cancer  except  in  cases  where  an  ulcer  is  undergoing  malignant  change. 

Eypochlorhydria. — A  diminished  secretion  of  hydrochloric  acid 
occurs  in  the  late  stages  of  chronic  gastritis,  in  gastric  neuroses,  in 
gastric  atrophy,  in  dilatation  of  the  stomach,  in  the  early  stages  of 
gastric  cancer,  and  sometimes  in  ulcer  when  associated  with  chronic 
gastritis  or  a  cachectic  condition.  It  is  also  diminished  in  fevers, 
wasting  diseases,  pernicious  anemia,  chlorosis,  neurasthenia,  etc. 

Anachlorhydria. — Hydrochloric  acid  is  absent  when  the  secreting 
glands  have  been  destroyed,  as  in  atrophic  catarrh  and  in  cancer  of 
the  stomach.  A  diagnosis  of  cancer,  however,  cannot  be  made  on 
this  alone;  the  hydrochloric  acid  must  be  constantly  absent  and 
other  corroborative  facts  must  be  present. 


476 


THE    STOMACH 


Hyperacidity,  or  an  increase  in  the  total  acidity,  may  be  the  result 
of  excessive  output  of  hydrochloric  acid  or  it  may  be  caused  by 
organic  acids  (lactic,  butyric,  and  acetic). 

Hypoacidity,  or  a  diminished  total  acidity,  denotes  a  deticicncy  in 
the  amount  of  hydrochloric  acid,  the  significance  of  which  has  been 
mentioned  above. 

Lactic  acid  is  the  result  of  bacterial  fermentation.  It  is  found  in 
appreciable  amounts  only  when  hydrochloric  acid  is  absent  and  in 
general  signifies  insufUciency  of  the  motor  power  and  stagnation  of 
the  stomach  contents,  as  is  found  in  dilatation,  obstruction  of  the 


Fig.  499. — Stomach-tube  and  funnel  for  expressing  the  stomach  contents,  a, 
Showing  the  lateral  fencstrae;  b,  funnel;  c,  mark  to  indicate  the  distance  from  the 
incisor  teeth  to  the  stomach. 

pylorus,  and  cancer.  The  presence  of  lactic  acid  alone  is  not  diag- 
nostic of  cancer,  as  small  amounts  may  be  found  after  a  meat  diet 
and  may  also  be  present  in  other  pathological  conditions,  nor  does  its 
absence  prove  the  nonexistence  of  cancer.  When,  however,  it  is 
found  in  considerable  amount  and  is  associated  with  an  absence  of 
hydrochloric  acid  and  with  deficient  motility,  it  is  strongly  sugges- 
tive of  cancer,  especially  if  the  Boas-Oppler  bacillus  is  also  present. 

Pepsin  and  rennin  are  only  absent  when  profound  organic  changes 
have  resulted  in  an  almost  complete  destruction  of  the  gastric 
mucous  membrane  as  the  result  of  chronic  inflammation,  severe 
atrophy,  etc.  The  presence  or  absence  of  these  ferments  is  thus  of 
importance  in  the  diagnosis  between  an  organic  change  and  a 
functional  condition. 

Extraction  of  the  Stomach  Contents. — The  stomach  contents 
may  be  removed  through  a  stomach-tube  either  by  the  aspiration  or 


EXTRACTIOX    OP    THE    STOiLA.CH    CONTEXTS 


477 


expression  method.  The  expression  method  answers  in  the  great 
majority  of  cases,  but  it  may  fail  where  the  contents  of  the  stomach 
are  not  fluid  enough  to  flow  through  the  tube.  The  use  of  the 
stomach-tube  is  contraindicated  in  the  presence  of  aortic  aneurysm,  in 
patients  Hable  to  cerebral  hemorrhage,  or  in  those  who  have  recently 
suft'ered  from  gastric  or  pulmonary  hemorrhages,  in  those  who  are 


Fig.  500. — Boas'  aspirating  bulb. 

very  weak,  in  those  sufl'ering  from  severe  pulmonary  or  cardiac 
troubles,  etc. 

Apparatus. — When  the  expression  method  of  removing  the 
stomach  contents  is  employed  the  following  apparatus  will  be  re- 
quired: A  soft-rubber  stomach-tube  about  30  inches  (75  cm.)  long 
and  1/4  of  an  inch  (6  mm.)  in  caliber,  with  two  smooth-edged  lateral 


Poh 


a  ins  /Jump 


jJ^macJi  n/6e 


Fig.  501. — Bottle  arranged  for  aspirating  the  stomach  contents,     c,  Large  glass 
bottle;  h,  tubing  connected  with  a  Potain  aspirator;  c,  the  stonach  tube. 

openings  and  a  blind  end,  connected  by  a  piece  of  glass  tubing  3  to  4 
inches  (7.5  to  10  cm.)  long  to  2  feet  (60  cm.)  of  rubber  tubing,  to  the 
end  of  which  a  glass  funnel  is  attached  (Fig.  499) . 

When  aspiration  is  employed,  the  stomach-tube  may  be  connected 
with  a  bottle  aspirator,  with  a  stomach-pump,  or  with  a  rubber- 
bulb  form  of  aspirator,  such  as  Boas  employs  (Fig.  500).  The  bottle- 
aspirator  (Fig.  501)  consists  of  a  large  glass  bottle  supplied  with  a 
tightly  fitting  rubber  stopper  through  which  two  glass  tubes  pass; 


478 


THE    STOMACH 


Fig.  502. — Introducing  the  stomach-tube.     First    step,   imparting   a   curv^e   to 
the  end  of  the  tube  for  its  more  easy  passage. 


Fig.  503. — Introducing  the  stomach-tube.     Second  step. 


EXTRACTION   OF   THE    STOMACH   CONTENTS 


479 


Fig.  504. — Introducing  the  stomach-tube.     Third  step. 


Fig.  505. — Aspiration  of  the  stomach  contents.     First  step. 


48o 


THE    STOMACH 


one  of  these  is  connected  with  the  stomach-tube  while  to  the  other  a 
Potain  syringe  is  attached,  by  means  of  which  the  air  in  the  bottle 
is  exhausted. 

Asepsis. — The  stomach -tube  should  be  sterilized  before  use. 

Position  of  the  Patient. — The  patient  is  seated  upright  in  a  chair 
or  in  bed. 

Technic. — Any  artificial  teeth  or  plates  should  be  removed  from 
the  patient's  mouth  and  he  should  be  protected  by  a  towel  or  an 


Fig.  506. — Aspiration  of  the  stomach  contents.     Second  step. 

apron  fastened  about  the  neck.  A  small  bowl  should  be  given  to 
him  for  the  purpose  of  receiving  any  excessive  secretion  of  mucus  or 
saliva  which  may  collect  in  the  mouth.  The  tube  is  moistened  in 
warm  water,  and  is  passed  into  the  patient's  open  mouth  back  to  the 
pharynx.  The  patient  is  then  requested  to  swallow,  and  the  instru- 
ment is  thus  advanced  into  the  esophagus,  partly  by  the  swallowing 
action  and  partly  by  the  operator  (Fig.  503).  During  this  ma- 
neuver the  patient  is  instructed  to  breathe  regularly  and  deeply,  even 
if  a  sense  of  suffocation  is  produced,  and  to  hold  the  head  slightly 


EXTRACTION    OF    THE    STOMACH    CONTENTS  48 1 

forward  to  alJow  the  escape  of  the  sahva  which  collects  in  the  throat 
(Fig.  504).  As  soon  as  the  tube  has  passed  the  entrance  of  the 
esophagus  it  may  be  readily  pushed  on  into  the  stomach  without 
any  difficulty.  The  distance  from  the  incisor  teeth  to  the  cardia  is 
about  16  inches  (40  cm.)  and  to  the  lower  border  of  the  healthy 
stomach  about  22  inches  (55  cm.),  but  in  pathological  conditions,  as 
in  dilatation,  for  example,  it  may  be  more.  When  the  tube  has  been 
introduced  for  the  proper  distance,  the  contents  of  the  organ  are 
removed,  either  by  expression  or  by  suction  furnished  from  one  of  the 
forms  of  aspirating  apparatus  described  above. 

Expression  of  the  stomach  contents  is  accomplished  by  pressing 
•over  the  region  of  the  stomach  while  the  patient  bends  forward  and 
strains  as  if  at  stool.  The  proximal  end  of  the  tube  is  in  the  mean- 
time lowered  over  a  dish  or  bowl  to  a  point  below  the  level  of  the 
stomach. 

Aspiration  with  the  Boas  aspirator  is  performed  as  follows:  With 
the  clamp  closed  the  operator  compresses  the  bulb  (Fig.  505)  and 
then  releases  it,  thus  filling  the  bulb  with  the  stomach  contents. 
The  clamp  is  then  opened  and  the  bulb  is  compressed,  causing  the 
contents  to  be  forced  out  into  a  receptacle  (Fig.  506). 

Variation  in  Technic. — Einhorn  employs  a  small   bucket  for 
withdrawing  samples  of  the  stomach  contents  at  various  periods  of 


Fig.  507. — Einhorn's  stomach  bucket. 

digestion.  In  this  way  the  chemical  composition  of  the  gastric  juice 
at  any  time  may  be  ascertained,  and  also  the  functional  activity  of 
the  stomach  may  be  determined,  by  noting  the  progress  of  diges- 
tion at  any  given  time  after  the  administration  of  a  test  meal. 

Einhorn's  apparatus  consists  of  an  olive-shaped  capsule  of  silver 
11/16  inch  (17  mm.)  long  and  5/16  inch  (8  mm.)  wide.  It  is  pro- 
vided with  an  opening  in  the  top,  above  which  is  a  cross-bar  to 
which  a  heavy  silk  thread  is  attached  (Fig.  507).  The  small  bucket 
is  moistened  and  placed  well  back  on  the  patient's  tongue  whence 
it  is  readily  swallowed.     It  is  allowed  to  remain  in  the  stomach  five 


482  THE    STOMACH 

minutes  and  is  then  carefully  removed  by  drawing  on  the  thread  and 
with  it  sufficient  of  the  stomach  contents  for  an  ordinary  examination 
of  the  acidity,  etc. 

TEST  OF  THE  MOTOR  FUNCTION  OF  THE  STOMACH 

By  the  motor  power  of  the  stomach  is  meant  the  ability  of  that 
organ  to  propel  its  contents  into  the  intestine.  When  this  function 
is  deficient,  as  from  obstruction  of  the  pylorus  due  to  cancer,  ulcer, 
etc.,  or  from  impairment  of  the  gastric  musculature,  food  accumu- 
lates in  the  stomach  and  dilatation  finally  results.  Early  recogni- 
tion of  perversion  of  the  motor  power  is  thus  of  great  importance. 
There  are  a  number  of  tests  for  determining  the  motor  function  of  the 
stomach,  among  which  are  the  following: 

Leu  he's  Test. — ^This  consists  in  giving  the  patient  a  test  meal 
composed  of  a  plate  of  soup,  a  beefsteak,  and  a  roll.  If  the  stomach 
is  empty  seven  hours  later  and  nothing  can  be  removed  by  lavage, 
the  motor  power  is  normal;  on  the  other  hand,  if  food  remains  in  the 
stomach  longer,  the  motor  power  is  deficient,  the  degree  of  impair- 
ment being  indicated  by  the  quantity  and  the  character  of  the  food 
remaining. 

Ewald's  Test. — This  consists  in  administering  salol  to  a  patient 
after  a  meal  and  noting  the  length  of  time  before  salicylic  acid  appears 
in  the  urine.  Salol  is  unaffected  by  the  gastric  juice,  but  is  split 
into  salicylic  acid  and  carbolic  acid  in  the  intestine.  In  perform- 
ing this  test  the  bladder  is  first  emptied;  the  patient  is  then  given  15 
grains  (i  gm.)  of  salol  in  two  gelatin-coated  capsules  and  is  in- 
structed to  urinate  at  intervals  of  half  an  hour  for  two  hours  and  to 
preserve  the  specimens  separately;  these  are  later  tested  with  neutral 
ferric  chlorid  solution  for  the  presence  of  salicylic  acid.  In  the  pres- 
ence of  salicylic  acid  the  test  gives  a  violet-blue  color.  In  normal 
cases  the  salicylic  acid  should  be  recognized  in  the  urine  in  from  thirty 
to  seventy-five  minutes.  Delay  in  its  appearance  indicates  deficient 
motor  power. 

lodipin  Test. — This  drug  is  unaltered  by  the  gastric  juice,  but  in 
the  intestine  it  is  split  up  and  iodin  is  absorbed  and  eliminated  in 
the  saliva.  Fifteen  grains  (i  gm.)  of  iodipin  are  administered  in 
gelatin-coated  capsules  in  the  morning  with  breakfast  and  the  saliva 
is  then  tested  with  starch-paper  and  nitric  acid  for  iodin  every  fifteen 
minutes.  In  a  normal  case  the  iodin  is  recognized  in  the  saliva 
within  about  an  hour. 


TB_A.XSILLUiIIXATIOX    OF    THE    STOMACH 


483 


TEST  OF  THE  ABSORPTION  POWER  OF  THE  STOMACH 

The  usual  method  of  determining  this  is  by  the  test  known  as 
that  of  Penzoldt  and  Faber.  It  is  performed  as  follows:  3  grains 
(0.2  gm.)  of  chemically  pure  potassium  iodid  are  given  in  a  gelatin- 
coated  capsule  on  an  empty  stomach,  and  the  urine  or  the  saliva  is 
then  tested  with  starch-paper  and  faming  nitric  acid  CA^ery  few  min- 
utes for  iodin.  Its  presence  is  indicated  by  a  blue  or  a  violet  reaction, 
lodin  should  normally  be  detected  in  the  saliva  and  urine  in  from  sLx 
and  a  half  to  fifteen  minutes  after  the  ingestion  of  the  iodid  of  potas- 
sium, while  its  appearance  is  considerably  delayed  if  the  absorp- 
tion power  is  interfered  with. 

TRANSILLUMINATION    OF   THE    STOMACH,    OR    G ASTRO - 

DIAPHANY 

A  method  introduced  by  Einhorn,  which  consists  of  transillumi- 
nating  the  stomach  by  means  of  a  small  electric  light  fastened  to  the 


Cross    Sectiorv^  (enUrged) 
Showing  inner  tube 
extending  throughoat 


Fig.    508. — Lynch's   gastrodiaphane.^     (From   a    drawing   in   the   possession    of 

Dr.  J.  M.  Lynch.) 


end  of  a  rubber  tube.  By  this  method  of  diagnosis  the  position  and 
size  of  the  stomach  may  be  determined,  and  the  presence  and  posi- 
tion of  a  growth  or  a  thickening  of  the  anterior  wall  of  the  stomach 
may  be  recognized  from  the  lack  of  transparency.  It  is  of  value  in 
the  diagnosis  of  dilatation  and  in  the  difi'erentiation  of  this  condi- 
tion from  gastroptosis.     In  the  former  the  illuminated  area  is  larger 

^  Made  bv  the  Electro-Surgical  Instrument  Co. 


484  THE    STOMACH 

than  normal,  while  in  the  latter  it  is  small  and  situated  low  down. 
Transillumination,  however,  is  not  used  as  a  routine,  since  it  is 
complicated  and  requires  special  apparatus,  furthermore,  there  are 
simpler  methods  of  determining  the  size  and  position  of  the  organ. 
One  advantage  of  the  method,  however,  is  that  the  organ  is  seen  in 
its  natural  condition,  whereas  under  inflation  it  is  apt  to  be  stretched 
beyond  the  normal.  To  employ  the  method  successfully  it  is  neces- 
sary that  the  patient  be  accustomed  to  the  insertion  of  the  stom- 
ach tube,  otherwise  retching  and  vomiting  will  interfere  with  the 
examination. 

Apparatus. — Einhorn's  gastrodiaphane  consists  of  a  small  Edi- 
son incandescent  lamp  attached  to  the  distal  end  of  a  soft-rubber 
stomach-tube.  The  wires  which  convey  the  electricity  to  the  lamp 
pass  down  inside  the  tube  while  at  the  proximal  end  are  two  screws 
for  attaching  the  wires  leading  from  the  battery.  A  six  to  eight 
dry-cell  battery  furnishes  the  necessary  power. 

Lynch  has  modified  Einhorn's  gastrodiaphane  by  employing  a 
longer  tube — 53  inches  (135  cm.)  long — sufficiently  long  to  pass 
through  the  pylorus — and  by  supplying  it  with  an  inner  auxiliary 
tube  through  which  the  stomach  may  be  inflated  with  air  or  water 
or  the  contents  of  stomach  or  duodenum  may  be  aspirated  (Fig.  508). 

Asepsis. — The  instrument  should  be  sterilized  before  use. 

Position  of  the  Patient. — The  examination  is  performed  with  the 
patient  in  the  erect  position. 

Technic. — Transillumination  must  be  performed  upon  an  empty 
stomach;  if  necessary,  the  stomach  should  be  first  emptied  by  means 
of  the  stomach-tube.  The  patient  is  then  given  two  glasses  of  water 
to  drink  to  prevent  overheating  the  stomach  from  the  lamp.  The 
tube  is  moistened  with  water  and  is  carefully  guided  into  the  phar- 
ynx and  the  patient  is  instructed  to  swallow,  the  descent  of  the  tube 
being  aided  by  the  operator  who  pushes  it  on  as  soon  as  it  is  well 
within  the  esophagus.  When  the  lamp  is  within  the  stomach,  the 
illumination  is  turned  on  and  the  room  is  darkened,  w^hile  the  results 
of  the  transillumination  are  noted.  A  bright  luminous  area  will  be 
noted  on  the  anterior  abdominal  wall  which  corresponds  in  size  to 
the  outhnes  of  the  stomach.  In  the  case  of  a  tumor  of  the  anterior 
stomach  wall,  even  if  too  small  to  be  felt,  a  dark  patch  will  appear  in 
the  illuminated  area. 

Variation  in  Technic. — In  order  to  increase  the  brilliancy  of  the 
transillumination,  Kemp  advocates  the  introduction  of  fluorescent 
media  into  the  stomach  preliminary  to  the  passage  of  the  gastrodia- 


GASTROSCOPY  485 

phane.  It  is  claimed  for  this  method  that  it  is  possible  to  perform 
a  satisfactory  transillumination  even  when  the  abdominal  walls  are 
very  thick. 

Two  media  are  employed:  Bisulphate  of  quinin  and  fluorescein. 
The  former,  which  gives  a  pale  violet  fluorescence,  is  administered 
in  the  proportion  of  bisulphate  of  quinin  gr.  x  (0.65  gm.)  to  i  pint 
(500  c.c.)  of  water  with  the  addition  of  5  tdj  (0.30  c.c.)  of  dilute 
phosphoric  or  sulphuric  acid  to  increase  the  acidity  and  so  intensify 
the  fluorescence. 

Fluorescein,  which  gives  a  green  fluorescence,  is  administered  as 
follows:  The  patient  is  given  8  ounces  (236  c.c.)  of  water  to  drink 
in  which  is  dissolved  15  grains  (i  gm.)  of  sodium  bicarbonate  to 
render  alkaline  the  acid  stomach  contents.  A  second  drink  is  then 
given,  consisting  of  8  ounces  of  water  (236  c.c.)  in  which  are  mixed 
1/2  to  1/4  grain  (0.008  to  0.0016  gm.)  of  fluorescein,  i  dram  (4  c.c.) 
of  glycerin,  and  15  grains  (i  gm.)  of  bicarbonate  of  soda.  After 
the  administration  of  the  fluorescent  medium  the  lamp  is  introduced 
and  the  examination  is  proceeded  with  as  above. 

GASTROSCOPY  '■ 

Gastroscopy  consists  in  the  insertion  into  the  stomach  of  a  stiff 
metal  tube,  illuminated  by  electricity,  through  which  the  interior  of 
the  organ  is  inspected.  This  method  of  examination  was  inaugu- 
rated by  Mikulicz  in  1881,  but,  on  account  of  its  limited  value  and 
the  technical  difficulties  in  the  use  of  the  older  instruments,  it  never 
came  into  general  use.  Later,  in  1890,  Rosenheim  devised  a  gastro- 
scope  on  similar  principles.  Both  these  instruments  were  made  with 
prisms  on  the  principle  of  the  cystoscope,  but  had  the  fatal  fault 
that  the  instrument  was  inserted  blindly  and  not  under  the  sight  of 
the  operator.  Chevalier  Jackson,  in  1906,  designed  a  gastroscope  on 
entirely  different  principles,  employing  large  tubes  with  the  illumina- 
tion at  the  distal  end,  similar  to  those  used  in  direct  tracheo-bron- 
choscopy  and  esophagoscopy,  and  he  thus  made  it  possible  to  ex- 
plore a  considerable  portion  of  the  stomach  by  direct  vision.  As  a 
rule,  from  two-thirds  to  three-fourths  of  the  stomach,  including  the 
pylorus,  is  available  for  examination  with  this  form  of  instrument, 
depending  upon  the  range  of  lateral  motion  of  the  hiatus  esophagei. 
A  stomach  which  occupies  a  vertical  position  presents  the  largest 
area  for  exploration  while  the  more  horizontally  the  organ  is  placed 
the  less  of  it  will  be  available  for  examination.     Furthermore,  under 


486  THE    STOMACH 

direct  view  gastroscopy  lesions  may  be  palpated  by  means  of  a 
probe  passed  through  the  instrument,  applications  may  be  made  to 
diseased  areas,  foreign  bodies  may  be  removed,  and  sections  of 
tumors  may  be  excised  for  microscopical  examination.  The  latest 
advance  in  gastroscopy  was  made  in  1910  by  Hill  in  conjunction 
with  Herschell,  who  combined  a  direct  and  indirect  view  esopha- 
gogastroscope  and  added  to  the  instrument  a  tap  for  inflating  the 
stomach  with  air. 

Gastroscopy,  however,  cannot  supplant  other  methods  of  diagno- 
sis. It  necessitates  that  the  patient  submit  to  a  general  anesthetic 
and  requires  such  experience  and  dexterity  on  the  part  of  the  operator 
for  its  proper  performance  as  to  place  it  outside  the  domain  of  any 
but  experts.  According  to  Jackson,  gastroscopy  is  without  danger 
other  than  that  from  the  anesthesia.  At  the  same  time,  the  opera- 
tion requires  great  skill  which  is  best  obtained  by  practising  upon  the 


(^^^ 


Fig.  509. — Jackson's  gastroscope. 

cadaver.  He  considers  the  operation  unadvisable  under  the  follow- 
ing conditions:  "In  the  profound  cachexia  of  the  last  stages  of  malig- 
nancy; in  the  profound  anemia  of  inanition  from  known  or  unknown 
causes;  cardiac,  pericardiac,  or  major  vascular  lesions;  general  or 
local,  acute  or  chronic  conditions  associated  with  either  dyspnea  or 
dropsical  effusions;  the  late  stages  of  organic  diseases,  as  cirrhosis 
of  the  liver,  etc."  Diseases  of  the  esophagus  may,  of  course,  interfere 
with  or  render  gastroscopy  out  of  the  question. 

Apparatus. — Jackson's  gastroscope  (Fig.  509)  consists  of  a  cylin- 
drical tube  about  ^2  inches  (80  cm.)  long  with  a  lumen  2/5  inch 
(10  mm.)  in  diameter,  and  with  a  thickened  distal  end.  In  the  wall 
of  the  instrument  are  two  small  accessory  tubes;  one  through  which 
the  illuminating  apparatus  is  inserted  and  the  other  for  the  purpose 
of  aspirating  fluids  that  may  interfere  with  the  examination.  To  the 
proximal  end  of  this  latter  tube  an  aspirating  apparatus  is  attached. 
The  instrument  is  also  provided  with  an  obturator  having  a  conical 
tip  to  facilitate  its  insertion. 


GASTROSCOPY 


487 


The  Hill-Herschell  esophagogastroscope  (Fig.  510)  for  combined, 
direct  and  indirect  gastroscopy  consists  of  a  direct  view  tube  with  the 
illumination  supplied  at  the  proximal  end  from  a  Brlinings  hand 
lamp  and  an  indirect  view  periscopic  tube  with  a  terminal  lamp, 
which  can  be  passed  through  the  direct  view  tube.  The  direct  view 
tube  is  supplied  with  a  cap  containing  a  plain  glass  window  and  a 
tap  through  which  air  can  be  forced  for  the  purpose  of  inflation.     A 


Fig.  510. — Hill-Herschell  esophagogastroscope.  a.  Direct  view  esphagoscope 
with  Briinings  lamp;  h,  indirect  view  periscope;  c,  shows  instrument  assembled 
for  gastroscopy. 

second  cap,  also  with  an  inflating  tap  and  with  a  rubber-lined  opening 
for  the  passage  of  the  indirect  view  tube,  is  provided.  Both  caps 
are  fastened  to  the  proximal  end  of  the  tube  by  means  of  a  bayonet 
joint. 

Asepsis. — The  tube  may  be  boiled  and  the  light-carrying  appara- 
tus may  be  sterilized  by  immersion  in  a  i  to  20  carbolic  acid  solution, 
followed  by  rinsing  in  alcohol,  or  alcohol  alone  may  be  employed. 

Preparations. — These  should  include  the  ordinary  preparations 
for  a  general  anesthetic;  that  is,  the  patient  is  given  a  cathartic  the 


488 


THE    STOMACH 


night  before  the  operation  and  food  is  withheld  for  a  period  of  twelve 
hours  before  the  operation  (see  also  page  2).  It  is  essential  that 
the  stomach  be  empty  when  gastroscopy  is  performed,  and,  if  neces- 
sary, lavage  of  the  stomach  should  be  practised  three  or  four  hours 
previous  to  the  operation.  In  dilatation  with  atony  preliminary 
lavage  is  a  necessity. 

Position  of  the  Patient. — The  patient  is  placed  in  the  recumbent 
posture  with  the  shoulders  brought  4  to  6  inches  (10  to  15  cm.)  over 


Fig.  511. — Position  of  patient  for  gastroscopy.      (After  Jackson.) 

the  edge  of  the  table  and  the  head  supported  by  an  assistant  seated 
at  the  head  of  the  table  and  to  the  right,  after  the  manner  shown  in 
the  accompanying  illustration  (Fig.  511).  This  assistant  also  con- 
trols the  mouth  gag.  Jackson  recommends  that,  as  soon  as  the  tube 
is  passed,  the  head  of  the  table  be  raised  a  distance  of  about  12 
inches  (30  cm.). 

Anesthesia. — General  narcosis  with  ether  is  employed.  Unless 
the  patient  is  deeply  anesthetized,  retching  will  take  place,  which 
will  not  only  interfere  with  the  examination,  but  may  make  the  pro- 
cedure a  dangerous  one. 

Technic. — i.  Direct  View  Gastroscopy. — The  mouth  gag  is  inserted 
and  the  operator  introduces  the  left  forefinger  into  the  patient's 


GASTROSCOPY 


489 


mouth  to  the  base  of  the  tongue  or  behind  the  epiglottis  and  draws 
the  tongue  forward.  The  gastroscope,  well  lubricated,  and  held  in 
the  operator's  right  hand,  is  then  introduced,  following  the  fore- 
finger, already  in  the  patient's  mouth,  as  a  guide  (Fig.  512).  At 
this  stage  the  assistant  who  controls  the  patient's  head  should  bend 


Fig.  512.^ — IMethod  of  inserting  the  gastroscope.      (After  Jackson.) 

the  patient's  neck  well  backward  so  as  to  bring  the  mouth  and 
esophagus  in  as  straight  a  line  as  possible.  As  soon  as  the  instru- 
ment has  been  passed  beyond  the  entrance  of  the  esophagus,  the 
obturator  is  withdrawn  and  the  light  is  turned  on.     The  instrument 


Fig.  513. — Showing  the  head  and  neck  of  patient  drawn  to  the  right  to  allow 
the  instrument  to  pass  through  the  hiatus  and  abdominal  esophagus.  (After 
Jackson.) 

is  passed  the  rest  of  the  w^ay  entirely  by  sight,  care  being  taken  to 
avoid  compressing  the  trachea  by  the  point  of  the  instrument.  To 
pass  the  hiatus  at  the  diaphragm,  the  instrument  is  rotated  in  such  a 
way  that  the  long  axis  of  a  cross  section  of  the  tube  corresponds  to 


490 


THE    STOMACH 


that  of  the  hiatus  (this  extends  from  behind  and  the  right  to  the  front 
and  the  left).  To  pass  the  abdominal  esophagus  as  it  bends  to  the 
left,  the  head  and  neck  of  the  patient  are  turned  to  the  right  (Fig. 
513).  When  the  tube  has  entered  the  stomach,  the  interior  of  the 
organ  should  be  systematically  explored  according  to  the  technic 
described  by  Jackson.^  which  the  writer  takes  the  hberty  of  quoting: 
"There  are  two  plans  of  exploration,  both  of  which  should  be 
carried  out.  First,  the  gastroscope  should  be  passed  down  carefully 
and  gently  to  the  greater  curvature,  inspecting  the  anterior  and  pos- 


FiG.  514. — Showing  the  patient's  head  and  neck  turned  to  the  left  to  aUow  the 
instrument  to  reach  the  pyloric  end.     (After  Jackson.) 

terior  walls.  At  times  these  walls  do  not  seem  to  be  fully  collapsed 
ahead  of  the  tube,  and  one  will  have  to  be  examined  first,  then  the 
other.  Then  the  tube  is  withdrawn,  inclined  slightly  laterally  in  the 
same  plane,  then  pushed  gently  downward  again  in  a  new  series  of 
folds.  This  is  repeated  until  the  extreme  pyloric  limit  is  reached. 
To  reach  this  limit  the  head  and  neck  of  the  patient  are  moved  to  the 
left,  with  the  tube  below  the  cardia  (Fig.  514). 

"After  the  whole  possible  range  has  been  covered  in  this  way 
we  proceed  to  the  second  plan.  The  tube  is  passed  down  until  the 
extremity  touches  the  wall  of  the  greater  curvature,  in  the  extreme 
left  of  the  possible  field.  Then  the  tube  is  moved  slowly  along  the 
greater  curvature,  but  not  in  too  close  contact  therewith,  until  the 
extreme  right  is  reached.  Withdrawing  the  tube  a  centimeter  or  two, 
the  field  is  slowly  swept  again  in  the  same  plane,  but  at  a  higher 

^Jackson.     Tracheo-bronchoscopy,  Esophagoscopy,  and  Gastroscopy,  page  149. 


GASTROSCOPY 


491 


level,  and  so  on,  upward  to  the  cardia.  Next  the  left  fingers  of  one 
skilled  in  abdominal  palpation  are  called  upon  to  manipulate  the 
unexplored  portions  over  the  front  of  the  tube.  This  is  sometimes 
better  accomplished  by  turning  the  patient  on  his  side,  first  on  one 
side,  then  on  the  other.  During  all  these  manipulations  the  tube 
must  be  withdrawn  within  the  esophagus;  when  the  stomach  is  in 
its  new  position,  the  gastroscope  is  again  pushed  downward  and  the 


Fig.  515. — The  passage  of  the  outer  tube  of  the  Hill-Herschell  esophago- 
gastroscope  through  the  esophagus  under  direct  vision.  (Mayo  Robson  in  Keen's 
Surgery.) 

newly  available  surfaces  are  explored.  Should  retching  supervene 
while  the  tube  is  in  the  esophagus,  no  harm  will  result,  but  when  the 
tube  is  in  the  stomach  retching  is  the  signal  for  immediate  with- 
drawal of  the  gastroscope  until  the  distal  end  of  the  tube  is  above  the 
diaphragm. 

"The  vertical  diameter  of  the  stomach  is  easily  determined  by 
measurement.  The  depth  from  the  teeth  to  the  cardia  is  taken,  then 
the  gastroscope  is  passed  on  down  until  the  greater  curvature  is 
encountered,  and  the  distance  from  the  teeth  is  again  taken.  The 
difference  between  this  and  the  first  measurement  gives  the  vertical 


492 


THE    STOMACH 


diameter  of  the  stomach  at  this  point.  Care  must  be  used  that  the 
measurements  are  not  rendered  inaccurate  by  pushing  the  greater 
curvature  downward,  which  is  exceedingly  easy  to  do  without  know- 
ing it  if  the  sense  of  touch  is  relied  upon  to  determine  when  the  lower 
wall  is  reached.  If  the  downward  progress  of  the  gastroscope  is 
watched  through  the  upper  orifice  it  is  easy  to  see  when  the  wall  at 
the  greater  curvature  is  touched.     Having  taken  our  measurements, 


Fig.  516. — Method  of  performing  indirect  view  gastroscopy  with  the  Hill-Her- 
schell  instrument.     (Mayo  Robson  in  Keen's  Surgery.) 

we  then  place  the  obturator  externally  parallel  to  the  tube  within  and 
indicate  to  the  abdominal  manipulator  the  exact  position  of  the  lower 
end  of  the  tube,  which  he  can  then  mark  on  the  skin,  giving  thus  with 
absolute  accuracy  the  exact  location  of  the  greater  curvature  of  the 
empty  stomach  at  that  point.  Care  must  be  taken,  of  course,  to 
resterilize  the  obturator  should  it  touch  anything  unclean." 

2,  Combined  Direct  and  Indirect  View  Gastroscopy. — The  outer 
direct  view  tube  is  passed  into  the  stomach  under  the  sight  of  the 
operator  (Tig.  515)  in  the  manner  previously  described  for  the  pass- 


EXPLORATORY  LAPAROTOMY  493 

age  of  Jackson's  gastroscope  (page  488).  With  the  tube  in  the  stom- 
ach the  cardiac  region  may  be  examined  by  direct  vision  under  in- 
flation. The  optical  window  and  the  hand  lamp  are  then  removed,  a 
handle  taking  the  place  of  the  lamp  and  the  perforated  cap  the  place 
of  the  glass  window.  The  indirect  view  tube  is  now  passed  through 
the  perforated  cap  and  outer  tube,  being  careful  to  begin  the  infla- 
tion before  it  enters  the  stomach  so  that  the  window  of  the  peri- 
scope will  not  be  sofled  from  contact  with  the  mucous  membrane. 
The  pylorus  is  first  located  (Fig.  516)  and  from  this  as  a  starting  point 
the  remainder  of  the  stomach  is  inspected  in  detail,  slowly  withdraw- 
ing and  turning  the  gastroscope  so  that  all  portions  are  brought  to 
view.  The  region  of  the  cardia,  however,  can  only  be  inspected  by 
direct  view. 

SKIAGRAPHY 

The  X-ray  is  useful  in  locating  foreign  bodies  impermeable  to  the 
rays  and  in  determining  the  size,  shape,  position,  and  peristaltic  move- 
ments of  the  organ.  By  inserting  a  long  soft  stomach-tube,  which  is 
filled  with  bismuth  or  shot,  in  the  stomach  along  the  greater  curva- 
ture and  then  taking  an  X-ray  while  the  patient  is  in  the  erect  posi- 
tion, the  outline  of  the  stomach  and  position  of  the  pylorus  have  been 
mapped  out.  Another  method  of  determining  the  size  and  position 
of  the  stomach  is  to  have  the  patient  swallow  keratin-coated  capsules 
of  bismuth  or  to  give  the  patient  on  an  empty  sto?nach  a  pint  (500  c.c.) 
of  milk,  kumiss,  mucilage  of  acacia,  or  gruel  into  which  two  ounces 
(60  gm.)  of  bismuth  subcarbonate  or  the  oxychlorid  of  bismuth  is 
suspended  by  a  thorough  mixing.  These  may  be  administered  shortly 
before  the  skiagraph  is  taken.  Pictures  should  be  taken  with  the 
patient  recumbent  and  in  the  erect  posture.  A  normal  stomach 
should  show  an  absence  of  bismuth  in  from  three  to  six  hours  after 
the  ingestion  of  the  bismuth  meal. 

EXPLORATORY  LAPAROTOMY 

An  exploratory  laparotomy  is  the  most  valuable  of  all  the  methods 
of  diagnosis  in  diseases  of  the  stomach,  and  in  many  cases  it  is  the 
only  method  by  which  a  correct  diagnosis  can  be  arrived  at.  It  is 
an  operation  that  only  requires  a  small  incision  and  which,  if  properly 
carried  out,  is  without  danger  to  the  patient.  The  ease  and  slight 
risk  with  which  it  may  be  performed  are,  however,  apt  to  lead  to 
neglect  of  other  simpler  methods  of  diagnosis  and  result  in  its  em- 


494 


THE    STOMACH 


ployment  in  far  too  radical  a  manner.  It  is  only  justifiable  where  a 
careful  trial  of  other  means  has  failed  to  establish  a  diagnosis.  Thus, 
for  example,  in  cases  where  a  cancerous  growth  is  strongly  suspected 
but  its  presence  cannot  be  verified,  or  where  a  palpable  tumor  of  the 
stomach  is  present,  and  there  is  a  question  as  to  its  character  and 
whether  it  can  be  removed  or  not,  an  exploratory  incision  is  certainly 
a  justifiable  procedure  and  its  prompt  performance  is  clearly  indicated, 
since  an  early  recognition  of  the  trouble  furnishes  the  only  hope  of 
cure.  The  surgeon  must  be  convinced,  however,  that  he  can  accom- 
plish something  for  the  relief  of  the  patient  before  it  is  attempted, 
and  he  must  be  prepared  to  carry  out  any  operative  procedure  that 
seems  indicated.  To  perform  an  exploratory  laparotomy  simply  for 
the  purpose  of  making  a  correct  diagnosis  in  an  individual  who  is 
manifestly  not  fit  for  a  severe  operation  or  upon  whom  it  is  evident 
that  the  performance  of  a  gastroenterostomy  would  give  scarcely 
any  hope  for  relief  of  his  symptoms  must  be  condemned. 

Therapeutic  Measures 

LAVAGE  OF  THE  STOMACH 

Lavage  consists  in  washing  out  the  stomach  by  introducing  water 
or  other  fluids  through  a  stomach-tube  or  catheter  and  then  siphon- 
ing it  off.  It  is  a  most  useful  therapeutic  procedure,  and  if  per- 
formed with  proper  precautions  is  without  danger. 

Indications. — Gastric  lavage  may  be  required  for  the  following 
purposes:  (i)  To  remove  poison  and  drugs  from  the  stomach.  (2) 
To  remove  mucus,  undigested  and  fermenting  food  from  a  dilated  or 
atonic  stomach  when  the  stomach  is  unable  to  empty  itself  of  its 
contents  after  eight  or  ten  hours.  In  such  conditions  lavage  is  espe- 
cially valuable,  as  it  cleanses  the  mucous  membrane  in  preparation 
for  fresh  food  and  thus  promotes  the  appetite;  at  the  same  time  the 
stomach  is  toned  and  strengthened.  (3)  To  withdraw  the  irritating 
material  from  the  stomach  in  acute  gastric  indigestion,  especially 
in  infants.  (4)  For  the  purpose  of  cleansing  the  stomach  in  prepara- 
tion for  gastric  operations.  (5)  In  intestinal  obstruction  and  per- 
itonitis with  fecal  vomiting  for  the  purpose  of  diminishing  the  vomit- 
ing and  at  the  same  time  removing  toxic  material  from  the  digestive 
tract;  and  as  a  preliminary  to  operation  in  such  cases  where  it  is  im- 
portant to  have  the  stomach  empty  to  avoid  the  danger  of  vomited 
matter  entering  the  air-passages.  (6)  Finally,  lavage  may  be  em- 
ployed when  it  is  desired  to  bring  medicated  solutions  in  contact 


LAVAGE   OF   THE   STOMACH 


495 


with  the  gastric  mucous  membrane,  though  a  more  efficacious  method 
is  by  means  of  the  stomach  douche. 

The  contraindications  to  lavage  are  practically  the  same  as  those 
given  against  the  use  of  the  stomach-tube  for  diagnostic  purposes, 
viz.,  in  the  presence  of  recent  gastric  hemorrhage,  in  acute  inflamma- 
tion of  the  stomach,  in  aortic  aneurysm,  in  advanced 
uncompensated  valvular  heart  lesions,  etc.  In 
cases  of  marked  general  arteriosclerosis  and  in 
general  weakness  or  prostration  it  should  be  used 
with  caution. 

Apparatus. — The  employment  of  a  stomach-pump 
is  not  advisable  on  account  of  the  danger  of  injuring 
the  mucous  lining  of  the  stomach;  instead,  an  ordi- 
nary siphonage  apparatus  should  be  employed.  This 
consists  of  a  soft-rubber  stomach-tube  joined  by 
means  of  3  to  4  inches  (7.5  to  10  cm.)  of  glass  tub- 
ing to  a  piece  of  rubber  tubing  2  or  3  feet  (60  to  90 
cm.)  long,  to  the  free  end  of  which  a  glass  funnel 
having  a  capactiy  of  about  a  pint  (500  c.c.)  is 
fitted  (see  Fig.  499).  The  stomach-tube  should 
be  about  30  inches  (75  c.c.)  long,  1/4  to  1/2  an 
inch  (6  to  12  mm.)  in  diameter,  and  should 
be  provided  preferably  with  a  closed  tip  and 
with  two  lateral  openings  of  fairly  large  size  so  as 
to  give  passage  to  solid  particles  of  food  (Fig. 
517).  These  openings  should  be  situated  as  close  to 
the  tip  as  possible.  The  tube  should  also  have  a 
mark  indicating  the  distance  from  the  upper  incisor 
teeth  to  the  stomach,  so  that  the  operator  may 
know  when  he  has  passed  it  a  sufficient  distance. 

For  an  infant  the  following  apparatus  may  be 
employed:  A  soft  rubber  catheter,  16  American  (24 
French)  in  size,  provided  with  a  large  lateral  eye  and  joined  by  a 
glass  connection  to  2  feet  (60  cm.)  of  rubber  tubing,  to  the  free  end 
of  which  an  8-ounce(25o  c.c.)  glass  funnel  is  attached.  In  addition, 
a  mouth  gag  may  be  required. 

Asepsis. — The  whole  apparatus  should  be  sterilized  by  boiling  or 
by  immersion  in  an  antiseptic  solution  and  then  rinsed  in  water  before 
using.  After  use  it  should  be  thoroughly  cleansed,  care  being  taken 
to  see  that  particles  of  food  are  not  left  adhering  to  the  interior  of  the 
tube,  especially  about  the  lateral  windows. 


Fig.    517.— 

Enlarged  view 
of  the  tip  of  a 
s  t  o  m  a  c  h-tube 
with  a  closed 
end  and  lateral 
fenestrse. 


496  THE    STOMACH 

Solutions  Employed. — For  cleansing  purposes  boiled  lukewarm 
water  is  generally  employed.  To  rid  the  stomach  of  mucus,  alkaline 
mineral  waters,  as  Carlsbad  or  Vichy,  or  Carlsbad  salt,  i  dr.  (4  gm.) 
to  I  quart  (1000  c.c.)  of  water,  or  sodium  bicarbonate  (i  to  5  per  cent.), 
may  be  employed. 

Temperature. — The  solution  should  be  of  a  temperature  of  from 
90°  to  100°  F.  (32°  to  38°  C). 

Quantity. — The  stomach  should  not  be  overdistended  with  solu- 
tion, about  a  pint  (500  c.c.)  being  introduced  at  a  time.  The  wash- 
ing-out process  is  to  be  continued,  however,  until  the  contents  of  the 
stomach  return  clear,  provided  the  patient's  condition  permits  it.  In 
some  cases  the  process  must  be  repeated  ten  or  twelve  times  before 
this  is  attained. 

Time  for  Lavage. — When  employed  to  remove  stagnated  food 
from  a  dilated  stomach,  lavage  may  be  performed  either  in  the  morn- 
ing before  the  first  meal  or  at  night,  three  or  four  hours  after  the  last 
meal.  The  former  time  is  preferable,  as  the  stomach  is  thus  given  all 
possible  opportunity  for  assimilation  of  its  contents  and  no  nourish- 
ment is  withdrawn.  In  some  cases,  however,  when  the  distress 
caused  by  the  flatulency  is  such  as  to  interfere  with  the  night's  rest, 
evening  lavage  is  indicated.  In  very  severe  cases  it  may  be  necessary 
to  wash  out  the  stomach  twice  a  day,  night  and  morning. 

Position  of  Patient. — The  patient  sits  in  a  chair  facing  the 
operator,  with  the  head  slightly  bent  forward.  If  the  patient's 
condition  is  such  that  this  is  not  advisable,  the  operation  may  be 
performed  with  the  patient  semiupright  in  bed.  A  child  should  be 
supported  in  a  sitting  position  upon  the  lap  of  a  nurse  with  its  head 
held  forward  by  an  assistant  so  as  to  allow  saliva  and  vomitus  to 
escape  from  the  mouth. 

Anesthesia. — In  case  gagging  is  excessive  the  pharynx  may  be 
sprayed  or  painted  with  a  5  per  cent,  solution  of  cocain.  This  is 
rarely  necessary,  however,  after  the  first  passage  of  the  tube. 

Technic. — Any  plates  or  artificial  teeth  should  be  removed  from 
the  patient's  mouth  and  an  apron  or  large  towel  should  be  fastened 
about  the  neck  and  allowed  to  hang  over  the  chest  and  lap  for  protec- 
tion. The  patient  should  be  given  a  small  bowl  to  catch  any  vomitus 
or  saliva  that  may  escape  from  the  mouth.  The  tube  is  then  well 
moistened  with  water  to  facilitate  its  passage.  Oily  lubricants 
should  be  avoided  on  account  of  the  disagreeable  taste.  As  a  rule, 
with  a  soft  tube  it  is  unnecessary  to  hold  the  base  of  the  tongue 
forward  or  to  guide  the  tube  in  place  by  the  lingers.     The  tube  is 


LAVAGE    OF    THE    STOMACH 


497 


simply  passed  along  the  roof  of  the  patient's  mouth  until  the  pharynx 
is  reached,  when  the  patient  is  instructed  to  swallow  and  the  instru- 
ment, grasped  by  the  pharyngeal  muscles,  is  carried  on  into  the 
esophagus  (see  Fig.  503).  At  first  there  may  be  some  irritation  and 
gagging,  but  by  having  the  patient  breathe  in  deeply  and  regularly 
this  rapidly  subsides.  When  a  patient  becomes  accustomed  to  the 
passage  of  the  tube  there  is  very  little  if  any  discomfort  produced. 


Fig.  518. — Showing  the  method  of  washing  out  the  stomach.     (After  Boston.) 

As  soon  as  the  tube  enters  the  esophagus  it  is  rapidly  pushed  on 
into  the  stomach.  Frequently  when  the  tube  enters  the  stomach  the 
contents  immediately  escape  into  the  funnel;  if  not,  the  funnel 
should  be  lowered  and  the  contents  drained  off.  To  accomplish  this 
it  may  be  necessary,  however,  to  apply  some  slight  pressure  over  the 
epigastrium,  after  the  method  employed  in  expressing  a  test-meal  (see 
page  481). 

Having  removed  the  contents  of  the  stomach,  or  being  sure  that 
it  is  empty,  the  tube  is  pinched  close  to  the  patient's  mouth,  and  the 
32 


498 


THE    STOMACH 


funnel  is  elevated  slightly  and  filled  with  about  a  pint  (500  c.c.)  of 
solution  (Fig.  518).  The  compression  is  then  removed  from  the 
tube  and  almost  the  entire  contents  of  the  funnel  is  allowed  to  slowly 
run  into  the  stomach,  enough  solution  being  kept  in  the  funnel,  how- 
ever, to  start  the  siphonage.  The  funnel  is  then  lowered  and  the 
contents  of  the  stomach  are  siphoned  back  into  the  funnel  and  dis- 
carded, care  being  taken  to  see  that  approximately  the  same  quantity 
returns  as  was  introduced  The  process  of  lavage  is  continued  by 
alternately  pouring  solution  into  the  stomach  through  the  funnel 


Fig.  519.— Showing  the  passage  of  a  stomach-tube  through  the  nose  in  performing 
gastric  lavage  upon  infants. 

and  then  removing  the  solution  by  siphonage.  In  order  to  reach  all 
portions  of  the  stomach  and  more  thoroughly  cleanse  the  mucous 
membrane,  it  is  well  to  have  the  patient  move  about  during  the  lav- 
age; for  example,  after  one  or  more  washings  in  the  upright  position 
have  the  patient  lie  down  and  then  roll  first  to  one  side  and  then  to 
the  other. 

At  the  completion  of  the  lavage  the  tube  should  be  removed  as 
follows:  A  small  quantity  of  fluid  is  allowed  to  remain  in  the  funnel 
and,  as  the  tube  is  slowly  withdrawn,  this  is  permitted  to  flow  back 
into  the  stomach  until  the  end  of  the  tube  is  in  the  esophagus.     The 


THE    STOMACH    DOUCHE  499 

tube  is  then  tightly  pinched  to  prevent  the  solution  from  escaping  as 
the  tube  is  withdrawn  over  the  larynx  and  through  the  mouth.  The 
important  point  is  that  the  tube  should  not  be  removed  from  the 
stomach  empty,  as  portions  of  mucous  membrane  may  be  drawn  into 
the  fenestrae  of  the  tube  and  be  lacerated  or  otherwise  injured. 

Variation  in  Technic. — In  insane  individuals  or  unruly  children 
who  try  to  prevent  the  passage  of  the  tube  by  refusing  to  open  the 
mouth  or  by  biting  the  instrument,  the  tube  may  be  passed  through 
a  nostril  (Fig.  519).  As  a  rule,  this  method  of  introduction  is  not 
difficult,  as  the  tube  hugs  the  posterior  wall  of  the  pharynx  and  readily 
enters  the  esophagus.  A  smaller-size  tube,  however,  is  required,  and 
care  should  be  taken  to  see  that  it  is  well  lubricated. 

THE  STOMACH  DOUCHE 

Gastric  douching  consists  in  irrigating  the  stomach  by  means  of 
solutions  introduced  under  pressure.  The  fluid  is  preferably  intro- 
duced through  a  tube  provided  with  many  small  lateral  openings,  so 
that  all  portions  of  the  mucous  lining  of  the  stomach  are  irrigated  by 
the  solution  which  flows  out  in  fine  streams  with  considerable  force. 
Either  plain  water  or  medicated  solutions  are  employed  in  the  douche. 

The  stomach  douche  is  useful  in  slight  degrees  of  motor  insuffi- 
ciency for  the  purpose  of  stimulating  peristalsis  and  secretion.  It  is 
also  employed  in  neuroses  affecting  the  sensory  apparatus  of  the 
stomach. 

Apparatus. — A  glass  funnel  with  a  capacity  of  i  pint  (500  c.c), 
a  piece  of  rubber  tubing  2  to  3  feet  (60  to  90  cm.)  long,  a  glass  con- 
necting tube  3  to  4  inches  (8  to  10  cm.)  long,  and  a  stomach- tube 
about  30  inches  (75  cm.)  long,  with  a  large  number  of  side  openings 
1/25  to  1/12  inch  (i  to  2  mm.)  in  diameter  and  a  terminal  opening 
1/8  to  1/6  inch  (3  to  4  mm.)  in  diameter,  should  be  provided  (Fig. 
520),  Tne  large  opening  in  the  end  of  the  tube  is  necessary  in 
order  to  drain  the  solution  quickly  out  of  the  stomach  and  at  the 
same  time  remove  any  solid  particles. 

Einhorn  has  devised  a  douche  apparatus  which  consists  of  a 
rubber  tube  26  inches  (65  cm.)  long  and  3/8  inch  (9  mm.)  in  diameter, 
terminating  at  the  stomach  end  in  a  hard-rubber  cap  with  numerous 
side  openings  and  a  large  end  opening  (Fig.  521).  Within  the  tip  of 
this  cap  lies  a  freely  movable  aluminum  baU  which  is  prevented  by 
two  crossbars  from  entering  the  main  portion  of  the  tube.  This  ball 
falls  over  the  terminal  opening  as  the  solution  flows  into  the  stomach 
and  causes  the  fluid  to  flow  out  through  the  small  openings.     When 


500 


THE    STOMACH 


the  current  is  reversed,  the  ball  is  driven  upward  and  the  solution  is 
carried  off  through  the  large  opening. 

Asepsis.' — The  apparatus  should  be  boiled  or  immersed  in  an  anti- 
septic solution  and  then  rinsed  off  before  use,  and  should  be  thor- 
oughly cleansed  after  use. 

Solutions, — Plain  boiled  water  is  usually  employed.  For  the 
removal  of  mucus,  alkaline  solutions,  as  sodium  bicarbonate  (i  to  5 
per  cent.),  Carlsbad  salt  i  dr.  (4  gm.)  to  i  quart  (1000  c.c.)  of  water, 
etc.,  are  used.     As  antiseptics  and  antifermentatives  are  the  follow- 


• 


Fig.  520. — An  enlarged  view  of  a 
stomach-douche  tube. 


Fig.  521. — Einhorn's  apparatus  for 
giving  a  stomach  douche. 


ing:  salicylic  acid  (0.3  per  cent.),  sodium  salicylate  (0.5  to  i  per 
cent.),  boric  acid  (2  to  3  per  cent.),  sodium  benzoate  (i  to  3  per  cent.), 
resorcin  (i  to  3  per  cent.),  creolin  (0.5  per  cent.),  lysol  (0.2  to  0.5  per 
cent.),  etc.  A  solution  of  silver  nitrate  in  the  strength  of  o.i  to  0.2 
per  cent,  is  sometimes  employed  as  an  astringent  to  diminish  sensa- 
tion and  salt  solution  (0.4  per  cent.)  to  increase  gastric  secretion. 
Chloroform  water  has  been  recommended  as  an  anodyne  in  gastralgia. 
Temperature. — As  a  general  rule,  the  solution  should  be  employed 
warm — at  a  temperature  of  90°  to  100°  F.  (32°  to  t,S°  C).     Occasion- 


THE    STOMACH   DOUCHE 


.501 


ally,  however,  the  alternate  use  of  a  warm  and  a  cold  douche  is  found 
beneficial. 

Time  for  Douching. — The  douche  should  be  employed  only  when 
the  stomach  is  empty.  The  most  effective  time  for  its  use  is  early  in 
the  morning  or  three  to  four  hours  after  the  first  meal. 

Amount  of  Pressure. — To  be  most  effective  the  solution  should  be 
introduced  under  considerable  pressure.  The  funnel  end  is  conse- 
quently raised  3  feet  (90  cm.)  or  more,  as  the  solution  is  flowing. 

Position  of  the  Patient. — The  douching  may  be  performed  with  the 
patient  sitting  upright  in  a  chair  or  in  bed,  but  in  order  to  bring 
the  solution  into  contact  with  all  portions  of  the  organ  this  position 
may  be  altered  from  time  to  time  with  advantage;  that  is,  changing 
from  the  upright  to  the  recumbent  and  first  upon  one  side  and  then 
upon  the  other. 


Fig.  522. — Showing  the  mechanism  of  the  stomach  douche.     (After  Gumprecht.) 

Anesthesia. — In  the  presence  of  excessive  irritation  or  gagging  the 
pharynx  may  be  sprayed  with  a  5  per  cent,  solution  of  cocain  as  a 
preliminary  to  the  passage  of  the  tube. 

Technic.^ — The  patient  is  given  a  small  bowl  to  receive  any  vom- 
ited matter  or  an  excessive  flow  of  saliva  and  his  chest  and  lap  are 
protected  by  an  apron.  The  tube  is  then  moistened  with  warm  water 
and  is  inserted  into  the  patient's  mouth,  being  kept  in  close  contact 
with  the  roof  of  the  mouth  until  the  pharynx  is  reached.  From 
this  point  on  the  tube  is  advanced  partly  by  the  action  of  the  pharyn- 
geal muscles  as  the  patient  swallows,  aided  by  the  operator  who  gently 
pushes  it  onward.  The  tube  is  inserted  only  a  sufficient  distance  to 
bring  the  perforated  tip  within  the  cardia  (Fig.  522),  which  is  deter- 
mined by  a  mark  placed  upon  the  tube  for  that  purpose.  The  funnel 
end  is  then  raised  and  a  pint  (500  c.c.)  of  solution  is  poured  into  the 
funnel,   the  tube  being  pinched  until  the  funnel  is  filled;  the  solu- 


502 


THE    STOMACH 


tion  is  then  allowed  to  flow  into  the  stomach,  the  funnel  end  being 
elevated  high  enough  to  obtain  the  necessary  pressure. 

To  remove  the  solution,  the  tube  is  pinched  while  there  is  still  some 
liquid  in  it  and  is  inserted  some  4  or  6  inches  (10  to  15  cm.)  further 
into  the  stomach,  so  that  its  end  will  lie  in  the  fluid  contents.  The 
funnel  end  is  then  lowered,  the  compression  of  the  tube  released,  and 
the  fluid  withdrawn  by  siphonage. 

The  stomach  should  first  be  thoroughly  washed  out  in  the  above 
manner  with  lukewarm  water,  using  several  pints  for  the  purpose. 
The  medicated  solution  is  then  introduced  in  the  same  manner,  but 
should  be  allowed  to  remain  only  from  a  half  minute  to  a  minute.  It 
is  then  siphoned  off,  and  the  stomach  is  again  douched  out  with  warm 
water.  The  tube  is  then  removed,  care  being  taken  to  compress  it 
between  the  thumb  and  forefinger  to  prevent  the  fluid  dripping  from 
it  into  the  larynx  as  it  is  withdrawn. 

GAVAGE 

Gavage  consists  in  introducing  food  into  the  stomach  by  means  of 
the  stomach-tube.  The  tube  may  be  passed  through  the  mouth  or 
through  the  nose.  The  latter  method  may  be  necessary  in  the 
case  of  infants  and  when  the  patient  struggles  against  the  passage 
of  the  tube  and  tries  to  bite  the  instrument. 

This  method  of  feeding  may  be  employed  after  intubation  and 
tracheotomy,  in  certain  operations  about  the  mouth  and  throat,  in 
cerebral  diseases,  when  the  patient  is  unconscious,  and  in  acute  dis- 
eases such  as  diphtheria,  scarlet  fever,  typhoid  fever,  etc.,  when  the 
patient  will  not  take  nourishment.  It  is  especially  valuable  in  phar- 
yngeal paralysis  when  the  patient  cannot  swallow  food  or  liquids. 
It  is  a  method  frequently  employed  in  feeding  premature  infants,  or 
children  suffering  from  malnutrition,  to  whom  otherwise  it  would  be  a 
difl&cult  matter  to  give  sufficient  food. 

Apparatus.^ — The  same  sort  of  apparatus  as  is  employed  for  gastric 
lavage  will  be  required,  viz.,  a  soft  stomach-tube  30  inches  (75  cm.) 
long,  2  feet  (60  cm.)  of  rubber  tubing  joined  to  the  stomach-tube  by  a 
glass  connecting  tube  3  or  4  inches  (7  to  10  cm.)  long,  and  a  glass 
funnel  with  a  capacity  of  about  i  pint  (500  c.c.)  (see  Fig.  499).  If 
it  is  intended  to  employ  the  apparatus  for  nasal  feeding,  a  tube  of 
smaUer  caliber  than  that  ordinarily  used  will  be  required.  For 
young  children  a  No.  10  American  (16  French)  catheter  should  take 
the  place  of  the  stomach-tube  (Fig.  523). 


GAVAGE 


503 


Asepsis. — Strict  asepsis  should  be  observed  in  the  care  of  the 
apparatus.  Before  use,  it  should  be  boiled  or  immersed  in  an  anti- 
septic solution  followed  by  a  thorough  rinsing  off  with  water,  and  after 
use  it  should  be  thoroughly  cleansed.  In  contagious  cases,  as  diph- 
theria, for  example,  the  apparatus  should  always  be  boiled. 

The  Food. — The  material  employed  for  feeding  will,  of  course, 
vary  according  to  the  indications  in  the  individual  case.  When  the 
digestive  power  of  the  stomach  is  impaired  predigested  food  should 


Fig.  523. — Apparatus  for  nasal  gavage. 

be  employed.  The  intervals  between  the  feedings  of  a  child  should 
be  somewhat  increased  when  gavage  is  employed. 

Position  of  Patient. — The  child  should  be  held  flat  on  its  back 
across  the  nurse's  knees  with  the  head  slightly  elevated.  Its  arms 
and  legs  may  be  confined  by  wrapping  it  in  a  sheet  from  the  chin  to 
the  knees. 

Technic. — The  tube  or  catheter  is  moistened  in  warm  water  and 
is  passed  into  the  mouth  to  the  base  of  the  tongue  and  then  gently 
down  the  esophagus  to  the  desired  depth  (Fig.  524).  In  an  infant  at 
birth  the  distance  from  the  alveolus  to  the  cardia  is  6  3/4  inches  (18 
cm.) ;  at  two  years  it  is  9  inches  (23  cm.) ;  at  ten  years  it  is  11  inches 
(28  cm.),  and  in  an  adult  it  is  about  16  inches  (40  cm.).  After  the 
tube  has  been  inserted  to  the  proper  depth,  the  funnel  is  elevated  and 


504 


THE    STOMACH 


Fig.  524. — Gavage.    First  step,  introduction  of  the  tube. 


Fig.  525. — Gavage.     Second  step,  administering  the  food. 


DUODEXAL    FEEDING 


505 


the  required  amount  of  food  introduced  (Fig.  525).  The  tube  is  then 
rapidly  withdrawn,  pinching  it  the  while,  so  as  to  prevent  an}'  dripping 
of  food  into  the  pharynx  and  larynx  (Fig.  526).  The  patient  should 
be  kept  quietly  in  the  recumbent  position  for  some  time  after  the  intro- 
duction of  the  food.  In  cases  complicated  by  gastroenteritis,  etc., 
a  preliminary  lavage  of  the  stomach  with  warm  water,  just  before 
gi^-ing  the  food,  is  often  ad\'isable.     It  removes  mucus  and  any  food 


Fig.  526. — Gavage.     Third  step,  showing  the  tube  being  compressed  as  it  is  re- 
moved to  prevent  leakage. 

remnants  of  a  previous  feeding,  cleanses  the  mucous  membrane,  and 
at  the  same  time  stimulates  it  to  a  better  absorption  of  the  freshly 
introduced  food. 


DUODENAL  FEEDING 

Duodenal  feeding  consists  in  the  administration  of  food  through  a 
small  tube  introduced  into  the  duodenum  through  the  stomach.  This 
method  of  feeding  is  sometimes  employed  in  conditions  where  it  is 
desired  to  keep  the  stomach  empty  and  at  rest,  as  in  gastric  and  duo- 


:o6 


THE    STOMACH 


denal  ulcer  and  gastric  dilatation  not  due  to  organic  obstruction.  It 
has  also  been  employed  in  cases  where  difficulty  is  found  in  adminis- 
tering the  proper  amount  of  nourishment,  as  in  nervous  vomiting, 
the  vomiting  of  pregnancy,  and  in  infants  who  do  not  retain  the  food 
given  by  gavage. 

Apparatus. — A  number  of  duodenal  tubes  have  been  devised  that 
can  be  used  for  feeding  purposes.  That  of  Einhorn  consists  of  a 
No.  8  French  tube  to  the  distal  end  of  which  is  attached  an  elongated 
perforated  brass  capsule  weighing  48  grs.  (3  gm.).  The  exterior  of 
the  tube  has  markings  at  40  cm.  (16  ins.),  56  cm.  (22  ins.),  70  cm. 
(28  ins.),  and  80  cm.  (32  ins.)  from  the  distal  end  to  indicate  the  po- 
sition of  the  capsule  after  it  has  been  swallowed.  A  three-way  stop- 
cock and  a  glass  syringe  complete  the  outfit  (Fig.  527). 


Fig.  527. — Einhorn's  duodenal  pump,  a,  Metal  capsule,  lower  half  provided 
with  numerous  holes,  the  upper  half  communicating  with  tube  b;  i,  li,  in,  marks 
of  I  =  40,  II  =  56,  III  =  70  cm.  from  capsule ;  c,  rubber  band  with  silk  attached  to  end  of 
tubing  which  can  be  placed  over  the  ear  of  the  patient;  d,  three-way  stop-cock; 
e,  collapsible  connecting  tube;/,  aspirating  syringe.     (Kemp.) 

Palefski  has  modified  Einhorn's  tube  by  emplo}dng  a  heavier  (105 
grs.  (6.5  gm.))  and  shorter  perforated  gold  plated  lead  ball,  which  it  is 
claimed  will  pass  into  the  duodenum  more  rapidly. 

For  infants  Hess  has  discarded  the  lead  ball  and  employs  a  Xo. 
14  to  15  French  soft  Nelaton  catheter  with  a  large  eye.  The  exterior 
of  the  catheter  has  markings  at  20  cm.  (8  ins.),  25  cm.(  10  ins.),  and 
30  cm.  (12  ins.)  from  the  eye. 

Preparation  of  the  Food.^ — ]Milk  and  eggs  are  the  foods  used. 
Where  the  patient  cannot  tolerate  milk,  barley  water  is  substituted. 
Einhorn  gives  the  following  mLxture:  milk  7  to  8  ozs.  (200  to  250  c.c), 
one  egg,  and  a  tablespoonful  of  lactose.  If  the  latter  produces  diar- 
rhea, it  is  omitted.  The  egg  is  beaten  in  the  milk  and  the  mixture  is 
strained  before  it  is  administered. 

Temperature  of  the  Food.^ — The  food  should  be  given  at  a  temper- 
ature of  100  F.  (38  C). 


MASSAGE   OF   THE   STOMACH  507 

Frequency  of  Feedings. — Eight  feedings  are  given  a  day  at  2-hour 
intervals. 

Technic. — The  operator  places  the  bulb  in  the  patient's  open 
mouth  and  instructs  him  to  swallow  it.  When  the  40  cm.  (16  ins.) 
mark  is  at  the  patient's  teeth,  the  lead  ball  should  be  at  the  cardia, 
and  at  this  stage  of  the  operation  the  patient  is  given  a  glass  of  water 
to  drink  and  is  instructed  to  lie  down  on  his  right  side  to  favor  by 
gravity  the  passage  of  the  ball  toward  the  pylorus.  When  the  56 
cm.  (22  ins.)  mark  is  at  the  teeth  the  bulb  should  be  at  the  pylorus, 
and  in  the  duodenum  when  the  70  cm.  (28  ins.)  mark  is  at  the  teeth. 
From  time  to  time  test  aspirations  are  made  to  recognize  more  cer- 
tainly the  position  of  the  tube,  that  is,  whether  it  is  in  the  stomach 
or  duodenum.  If  in  the  stomach,  secretion  will  be  obtained  and  will 
be  of  an  acid  reaction  while  from  the  duodenum  but  little  secretion 
can  be  withdrawn  and  it  will  be  neutral  or  alkaline  in  reaction. 
In  a  normal  case  it  requires  from  2  to  3  hours  for  the  ball  to  pass 
through  the  pylorus  and  a  considerable  longer  time  in  the  presence 
of  pyloric  spasm,  gastroptosis,  or  gastrectasis. 

With  the  bulb  in  the  duodenum,  the  food,  properly  heated  and 
strained,  is  drawn  into  the  syringe  and  is  then  slowly  injected.  After 
each  feeding  a  small  quantity  of  fluid  is  forced  through  the  tube  and 
then  some  air,  in  order  to  cleanse  the  tube  and  bulb  and  prevent  them 
from  becoming  clogged.  The  tube  is  left  in  place  during  the  course 
of  the  treatment,  being  fastened  to  the  patient's  ear,  and,  if  it  does 
not  produce  an  annoying  irritation  of  the  pharynx,  it  may  be  left  in 
place  from  10  to  12  days.  During  the  time  the  tube  is  worn,  the 
patient's  teeth  and  mouth  should  be  frequently  cleansed  with  a 
mouth  wash. 

MASSAGE  OF  THE  STOMACH 

Massage  systematically  and  properly  performed  is  a  valuable 
therapeutic  procedure  in  certain  diseases  of  the  stomach.  It  is 
applied  to  this  organ  with  the  same  object  in  view  as  when  used  upon 
other  muscular  organs;  that  is,  to  strengthen  weak  and  atonic  mus- 
cular walls  with  impaired  contractile  power.  Massage  also  aids  in  the 
propulsion  of  the  stomach  contents  into  the  intestine.  It  is  thus 
employed  with  success,  chiefly  in  cases  of  simple  atony  and  of  atonic 
dilatation,  and  to  a  lesser  degree  in  dilatation  due  to  pyloric  stenosis. 
Massage  is  advised  by  some  in  gastroptosis  for  the  purpose  of  strength- 
ening the  relaxed  ligamentous  supports.  Finally,  it  is  supposed  to 
stimulate  the  normal  secretions  of  the  stomach,  and  is  recommended 


;o8 


THE    STOMACH 


by  some  authorities  in  cases  with  impaired  gastric  secretion  and  in 
nervous  dyspepsia. 

Before  recommending  massage  an  exact  diagnosis  is  essential. 
Massage  is  contraindicated  in  acute  inflammation  of  the  stomach,  in 
recent  gastric  ulcers,  in  hemorrhage  from  the  stomach,  in  great  disten- 
tion of  the  stomach  from  gas,  and  in  inflammation  of  the  peritoneum. 
The  massage  should  be  performed  by  one  thoroughly  familiar  with 
the  technic 

Time  for  Massage. — This  will  depend  upon  the  purposes  of  the 
treatment.  When  employed  simply  for  the  purpose  of  toning  up  and 
strengthening  the  stomach  wall,  massage  is  best  performed  early  in 
the  morning  when  the  stomach  is  empty.     In  cases  of   dilatation, 


r^ 


Fig.  528. — Stroking  massage  applied  to  the  stomach.     (After  Ganl.; 

however,  the  object  is  to  propel  the  contents  of  the  stomach  into  the 
intestines,  and  the  massage  is  then  performed  upon  a  full  or  parti}' 
full  stomach.  The  best  time  for  this,  as  a  rule,  is  six  to  seven  hours 
after  the  principal  meal  of  the  day. 

Frequency. — The  massage,  to  be  of  any  value,  should  be  per- 
formed every  day. 

Duration. — During  the  first  treatments  the  manipulations  should 
be  of  short  duration — about  two  to  three  minutes  at  a  sitting — and 
later,  as  the  patient  becomes  more  accustomed  to  the  treatment,  the 
sitting  may  be  extended  to  periods  of  live  to  ten  minutes. 

Position  of  the  Patient. — The  patient  lies  upon  his  back  with  his 
head  slightly  raised  and  the  legs  flexed  so  as  to  relax  the  abdominal 
muscles. 


ELECTROTHERAPY    IN    DISEASES    OF    THE    STOMACH 


509 


Technic. — Stroking  movements  (effleurage)  and  kneading  (petris- 
sage) are  the  manipulations  most  employed.  In  performing  effleur- 
age the  operator  places  his  left  hand  upon  the  right  hypochondriac 
region  for  the  purpose  of  counterpressare  and  with  his  right  hand,  the 
lingers  of  which  are  outstretched,  he  performs  stroking  movements 
from  the  fundus  toward  the  pylorus;  i.e.,  from  left  to  right  (Fig.  528). 

Kneading  of  the  stomach  may  alternate  with  these  stroking  move- 
ments to  advantage.  In  these  manipulations  large  folds  of  the 
abdominal  wall,  including  the  stomach,  are  picked  up  between  the 
thumb  and  four  fingers  of  the  two  hands  by  deep  handgrasps  and  are 
kneaded  by  alternately  squeezing  and  relaxing  the  fingers  (Fig.  529). 
The  force  used  in  the  various  movements  of  massage  will  depend  upon 


Fig.  529. — Kneading  massage  applied  to  the  stomach. 

the  sensitiveness  of  the  patient,  the  thickness  of  the  abdominal  walls, 
and  the  rigidity  of  the  muscles.  The  manipulations,  however,  should 
never  produce  pain  or  be  disagreeable  to  the  patient. 

To  accelerate  the  passage  of  the  stomach  contents  into  the  intes- 
tines, the  fundus  of  the  stomach  and  contents  are  grasped  through 
the  abdominal  walls  between  the  thumb  and  fingers  of  the  right  hand 
and  by  propulsive  movements  directed  backward  an  attempt  is  made 
to  throw  the  contents  of  the  stomach  toward  the  pylorus. 


ELECTROTHERAPY  IN  DISEASES  OF  THE  STOMACH 

Electricity  has  undoubted  beneficial  effects  upon  certain  diseases 
of  the  stomach,  although  the  manner  in  which  the  electric  current 
acts  is  not  well  understood,  and  the  experimental  evidence  of  its  value 
is  both  contradictory  and  in  some  cases  not  in  accord  with  the  results 
obtained  clinically.     It  seems  probable,  however,   that  electricity 


lO 


THE    STOMACH 


increases  the  motor  activity,  stimulates  the  secretion  of  the  gastric 
juice,  and  increases  the  absorption  power  of  the  stomach.  According 
to  cHnical  experience,  at  any  rate,  its  use  is  followed  by  favorable 
results  in  simple  atony,   dilatation   from   atony,  hypochlorhydria, 


Fig.  530. — Large  Hal  sponge  electrode. 

nervous  anorexia,  nervous  vomiting,  paresthesia,  hyperesthesia,  and 
gastralgias. 

Both  the  faradic  and  the  galvanic  currents  are  employed  and  they 
may  be  used  percutaneously  or  intraventricularly.     As  to  the  choice 


Fu..  531. — Einhorn's  deglutible  electrode. 

of  current  and  the  method  of  its  application,  authorities  again  disagree. 
The  majority,  however,  advise  the  use  of  the  faradic  currents  when 
the  motor  functions  are  diseased  and  the  galvanic  in  neuroses  and  in 
cases  where  the  secretory  apparatus  is  at  fault.  The  intraventricular 
method  seems  more  desirable  when  the  necessary  apparatus  is  at 
hand,  as  the  stomach  is  thus  directly  tre9,ted.     External  application 


ELECTROTHERAPY    IN    DISEASES    OF    THE    STOilACH  511 

of  electricity,  on  the  other  hand,  is  simpler  to  carry  out  and  is  a  less 
disagreeable  method  for  the  patient. 

Apparatus. — For  the  percutaneous  application  there  will  be 
required  two  curved  flat  electrodes  of  about  9  square  inches'  surface 
(500  to  600  sq.  cm.)  (Fig.  530).  For  intrastomacbic  application  a 
special  gastric  electrode,  such  as  Bardet's,  Stockton's,  or  Wegele's, 
inserted  within  a  stomach-tube,  may  be  employed  or  Einhorn's  deglu- 
tible  electrode  may  be  used.  The  latter  (Fig.  531)  consists  of  a  hard- 
rubber  shell,  shaped  like  an  egg,  with  numerous  small  perforations 
piercing  its  surface,  and  within  this  capsule  is  a  button  of  copper  or 
brass.  A  small  rubber  tube  1/25  inch  (i  mm.)  in  diameter  carries 
fine  wires  leading  from  the  button  to  the  instrument.  A  curved  plate 
electrode  is  connected  mth  the  other  pole  of  the  battery. 

Duration  of  Application. — Each  treatment  should  consume  about 
ten  minutes. 

Frequency. — At  first  treatments  are  employed  daily;  after  two  or 
three  weeks,  twice  weekly;  and,  finally,  apphcations  are  made  at 
weekly  intervals  until  the  treatments  are  discontinued. 

Strength  of  Current. — For  galvanism  from  15  to  20  ma.  are  ordi- 
narily used.  With  the  faradic  current  it  is  not  possible  to  measure 
exactly  its  strength;  the  current  should  be  strong  enough,  however,  to 
produce  strong  and  visible  contractions  of  the  abdominal  wall  and 
back  muscles  without  causing  pain. 

Position  of  Patient. — The  patient  should  be  in  the  recumbent 
position  with  the  head  slightly  elevated  and  legs  flexed  so  as  to  relax 
the  abdominal  muscles. 

Technic. — i.  Percutaneous  Application. — The  two  electrodes  are 
well  moistened  and  the  negative  pole  is  placed  over  the  region  of  the 
pylorus,  the  positive  over  the  spine  in  the  region  of  the  seventh  or 
eighth  dorsal  vertebra.  The  negative  electrode  may  be  held  station- 
ary for  short  periods  or  may  be  moved  about  over  the  parts  with 
friction  during  the  treatment.  Either  the  faradic  or  the  galvanic 
current  may  be  employed. 

2.  Intra  stomachic  Application. — The  treatment  should  be  given  on 
an  empty  stomach,  preferably  one  or  two  hours  after  a  light  breakfast. 
If  necessary,  the  stomach  should  be  emptied  by  means  of  a  stomach- 
tube.  When  an  electrode,  such  as  Wegele's  or  Stockton's,  is  em- 
ployed, it  is  introduced  in  the  same  manner  as  a  stomach-tube.  One 
or  two  glasses  of  water  are  then  introduced  into  the  stomach  through 
the  tube  or,  if  Einhorn's  electrode  is  used,  before  the  electrode  is 
swallowed.     In  introducing  this  latter  the  patient  should  be  requested 


512  THE    STOMACH 

to  open  the  mouth  widely  and  the  electrode  is  placed  well  back  in  the 
patient's  mouth  and  the  patient  is  then  instructed  to  swallow.  If 
there  is  any  difficulty  in  accompU?hing  this,  drinking  a  glass  of  water 
will  be  of  material  assistance. 

The  gastric  electrode  is  connected  with  the  negative  pole  of  the 
battery,  the  positive  pole  is  connected  to  a  plate  electrode.  This 
electrode  is  applied  for  part  of  the  seance  over  the  region  of  the  stom- 
ach, held  in  one  place  for  a  few  moments  at  a  time.  A  smaller 
sponge  electrode  is  then  substituted  and  is  moved  about  over  the 
region  of  the  stomach  from  left  to  right  for  several  minutes,  and  is 
then  shifted  to  the  spine  in  the  region  of  the  seventh  or  eighth  dorsal 
vertebra  where  it  is  allowed  to  remain  a  minute  or  more,  and  finally 
it  is  applied  once  more  to  the  epigastrium  over  which  it  is  gently 
moved  for  a  minute  or  so.  The  current  is  then  gradually  decreased 
and  the  gastric  electrode  removed. 


CHAPTER  XVIII 
THE  COLON  AND  RECTUM 

Anatomic  Considerations 

The  Colon. — The  colon  is  that  portion  of  the  alimentaty  canal 
lying  between  the  small  intestine  and  the  rectum.  It  is  5  to  6  ft. 
(150  to  180  cm.)  long  and  in  its  widest  portion,  the  cecum,  measures 
3  1/8  inches  (8  cm.)  in  diameter.  The  average  capacity  of  the  colon 
in  infants  is  i  pint  (500  c.c),  at  2  years  2  1/2  pints  (1.25  liters),  and  in 
adults  9  pints  (4.5  liters.) 


Fig.   532. — -The  course  and  position  of  the  colon. 

It  is  divided  into  the  cecum,  ascending  colon,  transverse  colon, 
descending  colon,  and  sigmoid  colon. 

The  cecum,  lying  in  the  right  iliac  fossa  below  the  ileocecal  valve, 
is  3  1/8  inches  (8  cm.)  broad  and  2  1/2  inches  (6  cm.)  long.  It  is 
usually  completely  covered  by  peritoneum.  From  its  inner  and  pos- 
terior portion  is  given  off  the  vermiform  appendix,  a  small  blind  tube 
with  an  average  length  of  3  1/4  inches  (8  cm.).     The  ileum  opens  into 

513 

33 


514  THE  COLON  AND  RECTUM 

the  cecum  at  a  point  just  above  the  origin  of  the  appendix.  Regurgi- 
tation of  fluids  and  gases  into  the  small  intestine  is  prevented  by  the 
ileocecal  valve,  a  slit-like  opening  at  right  angles  to  the  long  axis  of 
the  bowel. 

The  ascending  colon  is  8  inches  (20  cm.)  long.  It  extends  vertically 
up  the  right  side  of  the  abdomen  from  the  cecum  to  the  inferior  sur- 
face of  the  liver  to  the  right  of  the  gall-bladder,  where  it  turns  to  the 
left  as  the  hepatic  flexure.  It  passes  in  front  of  the  posterior  abdom- 
inal muscles  and  the  lower  pole  of  the  kidney,  and  is  bound  to  the 
former  by  connective  tissue.  Anteriorly  and  laterally  it  is  covered 
by  peritoneum. 

The  transverse  colon  is  about  20  inches  (51  cm.)  in  length.  It  ex- 
tends from  the  hepatic  flexure  across  the  abdomen  below  the  liver  and 
greater  curvature  of  the  stomach,  with  a  slight  downward  curve  at 
its  center,  to  the  spleen,  where  it  turns  downward  as  the  splenic 
flexure.  The  transverse  colon  is  the  most  movable  portion  of  the 
large  gut,  being  connected  with  the  posterior  abdominal  wall  by  a 
long  mesentery. 

The  descending  colon  is  8  1/2  inches  (21  cm.)  long.  It  extends  down 
the  left  side  of  the  abdomen  from  the  splenic  flexure  to  the  sigmoid, 
lying  in  front  of  the  left  kidney  and  posterior  abdominal  muscles. 
Anteriorly  and  laterally  it  is  covered  by  peritoneum. 

The  sigmoid  colon  is  the  narrowest  portion  of  the  large  gut.  It  is 
about  17  1/2  inches  (44  cm.)  long  and  extends  from  the  left  iliac  crest 
in  an  S-shaped  curve  to  the  third  sacral  vertebra.  In  the  first  portion 
of  its  course  it  passes  downward  almost  to  Poupart's  ligament,  then 
turns  from  the  left  to  the  right  to  enter  the  pelvic  cavity  near  the 
mid-line,  and  passing  to  the  right  side,  it  turns  upward  as  far  as  the 
lower  margin  of  the  right  iliac  fossa.  From  this  point  it  makes  a 
sudden  turn  and  passes  downward,  backward,  and  inward  to  become 
continuous  with  the  rectum.  The  sigmoid  is  very  movable,  having 
a  complete  peritoneal  covering  and  mesosigmoid.  At  the  junction 
with  the  rectum  the  gut  exhibits  a  marked  narrowing  from  an  increase 
of  the  muscular  fibers,  known  as  the  sphincter  of  O'Beirne. 

The  Rectum. — The  rectum  commences  at  the  sigmoid  flexure, 
opposite  the  third  sacral  vertebra,  and  descends  in  the  middle  line  of 
the  sacrum  and  coccyx.  As  it  descends  it  forms  a  curve  with  the 
concavity  forward  until  it  reaches  a  point  about  i  inch  (2.5  cm.) 
below  the  tip  of  the  coccyx  where  it  turns,  forming  a  sharp  angle,  and 
is  then  continued  downward  and  backward  through  the  thickness  of 
the  pelvic  floor  as  the  anal  canal  (Fig.  533).     The  antero-posterior 


ANATOillC    CONSIDERATIONS 


515 


curves  of  the  rectum  are  distinct  and  a  knowledge  of  their  direction 
is  important  for  the  proper  introduction  of  the  finger  or  instruments 
in  making  an  examination.  There  are  also  two  slight  lateral  curves, 
first  to  the  right  and  then  to  the  left,  but  of  less  practical  importance. 

For  purposes  of  description  the  rectum  may  be  divided  into  the 
rectum  proper  and  the  anal  canal. 

The  rectum  proper  extends  from  the  middle  of  the  third  sacral 
vertebra  to  the  upper  border  of  the  internal  sphincter  muscle,  or  to 
about  the  level  of  the  apex  of  the  prostate  gland,  and  measures  3  to 
4  inches  (7.5  to  10  cm.")  in  length.     This  portion  of  the  rectum  is 


Fig.  533. — Sagittal  section  of  the  rectum. 

sacculated  in  form,  exhibiting  three  pouches  or  dilatations,  of  which 
the  lowest  and  largest,  called  the  ampulla,  measures  in  some  cases 
nearly  10  inches  (25  cm.)  in  circumference.  The  constrictions  be- 
tween which  lie  these  dilatations  are  produced  by  an  infolding  of  the 
coats  of  the  bowel  in  the  formation  of  the  so-called  rectal  valves.  In 
the  male,  the  rectum  is  in  relation  anteriorly  with  the  recto-vesical 
pouch,  the  trigone  of  the  bladder,  the  seminal  vesicles,  and  the  pros- 
tate gland,  while  in  the  female,  the  vagina  and  the  recto-vaginal 
pouch  with  the  small  intestine  therein  contained  He  anteriorly. 

The  anal  canal  is  about  i  1/2  to  2  inches  (4  to  5  cm.)  long. 
It  extends  downward  and  backward,  terminating  at  the  surface  of  the 
body  as  the  anus.  This  portion  of  the  rectum  has  no  peritoneal 
covering.  It  is  embraced  by  the  internal  sphincter  muscle  and  is 
supported  by  the  levatores  ani  muscles.     At  the  anus  the  skin  is  dark 


5l6  THE  COLON  AND  RECTUM 

brown  in  color  and  puckered  up  into  radiating  folds.  The  anal  canal 
is  in  relation  anteriorly  in  the  male  with  the  bulb  and  membranous 
portion  of  the  urethra;  and  in  the  female  the  perineal  body  separates 
it  from  the  lower  end  of  the  vagina. 

The  rectum  is  lined  with  a  dark  and  vascular  mucous  membrane, 
which  is  thrown  into  a  series  of  folds,  the  most  important  of  which  are 
known  as  Houston's  valves,  or  the  rectal  valves.  These  are  three — 
sometimes  two  or  four — semilunar  folds,  projecting  Hke  transverse 
shelves  into  the  cavity  of  the  bowel  when  it  is  distended.  According 
to  the  usual  arrangement  the  inferior  fold  projects  from  the  left  wall 
of  the  rectum  at  a  point  about  2  inches  (5  cm.)  above  the  anal  orifice; 
the  middle  and  most  constantly  present  one  projects  from  the  right 
wall  at  a  point  situated  3  inches  (7.5  cm.)  from  the  anus;  while  the 


Fig.  534. — The  rectal  valve  as  seen  thiuugh  the  proctoscope.     (After  Gant.) 

superior  fold  projects  from  the  left  wall  near  the  third  sacral  vertebra, 
or  at  a  point  about  i  inch  (2.5  cm.)  above  the  middle  fold  (Fig.  534). 
These  valves  are  attached  to  the  walls  of  the  rectum  for  a  distance 
of  from  1/3  to  1/2  its  circumference  and  protrude  into  its  cavity 
to  varying  degrees.  Their  function  seems  to  be  to  assist  the  sphinc- 
ters and  to  serve  to  support  the  fecal  mass.  They  may  be  the  cause 
of  difficulty  in  making  digital  examinations  and  they  may  act  as  ob- 
stacles to  the  passage  of  a  rectal  tube. 

In  the  anal  canal  the  mucous  membrane  is  thrown  into  a  series 
of  longitudinal  folds,  five  to  twelve  in  number,  called  the  columns  of 
Morgagni.  They  are  about  1/2  inch  (i  cm.)  in  length,  and  are  pro- 
longed upward  from  the  radiating  folds  about  the  anus.  Stretched 
between  these  columns  at  their  inferior  ends  are  semilunar  folds  of 
mucous  membrane  forming  pouches  that  open  upward,  known  as  the 
valves  of  Morgagni  (Fig.  535). 


DIAGNOSTIC    METHODS 


517 


Diagnostic  Methods 

Assuming  that  the  usual  lines  of  inquiry  common  to  all  histories 
have  been  followed  and  it  having  been  ascertained  whether  there  is  a 
past  record  of  syphilis,  gonorrhea,  dysentery,  typhoid  fever,  appen- 
dicitis, peritonitis,  pelvic  inflammation,  gall-stones,  etc.,  which  might 
result  in  adhesions,  ulceration,  stricture,  or  tumor,  inquiry  is  then 
directed  to  special  symptoms. 

In  the  presence  of  pain,  its  location,  whether  in  the  abdomen, 
rectum,  pelvis,  or  neck  of  the  bladder;  its  character,  whether  sudden 
in  onset,  acute  and  cutting,  or  a  dull  ache;  and  the  time  of  day  it  is 
felt,  that  is,  before  or  after  stools  or  with  every  stool,  will  often  fur- 


FiG.  535. — The  anal  canal,  showing  the  columns  and  valves  of  Morgagni. 

nish  a  clue  as  to  the  cause.  Pain  in  the  upper  part  of  the  abdomen 
is  suggestive  of  gastric,  duodenal,  or  gall-bladder  affections.  Pain  in 
the  right  iliac  fossa  may  be  due  to  appendicitis  or  to  involvement  of 
the  cecum.  Pain  situated  in  the  central  portion  of  the  abdomen  is 
frequently  caused  by  colic  from  gas,  feces,  or  mechanical  obstruction, 
though  not  infrequently  early  in  appendicitis  the  pain  is  in  this  local- 
ity. Colic  is  characterized  by  short,  sharp  pains  coming  on  suddenly 
and  often  shifting  in  location;  furthermore,  the  passage  of  gas  or  feces 
usually  gives  relief.  Constant  or  prolonged  pain  is  more  apt  to 
signify  some  organic  lesion.  Frequently  in  place  of  pain  patients 
will  complain  of  more  or  less  discomfort  or  tenesmus  in  the  anus  or 
rectum.  It  is  a  frequent  symptom  in  dysentery  and  in  many  other 
affections  of  the  rectum. 


5l8  THE  COLON  AND  RECTUM 

If  abdominal  distention  is  complained  of,  it  should  be  ascertained 
whether  it  is  general  or  localized  and  whether  there  is  any  passage 
of  gas  from  the  bowels,  and,  if  so,  whether  it  relieves  the  condition, 
A  total  absence  of  flatus  with  obstinate  constipation  suggests  ob- 
struction. 

Finally,  the  habitual  state  of  the  bowels  should  be  determined, 
that  is,  whether  they  are  normal,  constipated,  or  loose,  or  whether 
constipation  and  diarrhea  are  alternately  present.  The  examiner 
should  also  inquire  as  to  the  color,  odor,  and  character  of  the  move- 
ments, whether  soft  or  hard,  large  or  small,  and  whether  they  contain 
mucus,  pus,  or  blood.  The  amount  and  contour  will  vary  much  in 
health  as  well  as  in  disease,  depending  upon  the  form  of  food  taken, 
the  quantity  of  water  imbibed,  etc. 

When  all  possible  information  has  been  obtained  from  a  history 
and  general  physical  examination,  a  local  examination  is  made  to 
determine  more  accurately  the  cause  of  the  symptoms  complained  of 
and  the  proper  line  of  treatment  to  pursue.  Especially  is  it  import- 
ant to  make  a  systematic  examination  in  the  presence  of  rectal 
symptoms.  On  account  of  the  close  relation  and  anatomic  prox- 
imity of  other  pelvic  organs,  as  the  uterus,  tubes,  and  ovaries  in  the 
female  and  the  bladder,  urethra,  prostate,  and  seminal  vesicles  in  the 
male,  it  is  necessary  to  be  able  to  differentiate  between  many  affec- 
tions the  symptoms  of  which  may  reflexly  simulate  an  abnormal 
condition  of  the  rectum.  It  is  not  uncommon  for  a  stricture  of  the 
urethra,  an  enlarged  prostate,  a  stone  in  the  bladder,  or  a  displace- 
ment of  the  uterus,  for  example,  to  produce  a  set  of  symptoms  which 
point  to  the  rectum  as  their  seat. 

The  methods  available  for  examination  of  the  colon  and  rectum 
include  abdominal  inspection,  palpation,  and  percussion,  ausculta- 
tion, inflation  of  the  colon,  skiagraphy,  rectal  inspection  and  palpa- 
tion, proctoscopy,  examination  by  sounds  and  bougies,  examination 
by  the  probe,  lavage  of  the  bowel,  and  examination  of  the  feces. 

/.  Abdominal  Examination 

INSPECTION 

In  a  thin  individual  it  is  often  possible  to  make  a  diagnosis  of 
ptosis,  tumors,  or  constrictions  of  the  colon  from  the  appearance  and 
shape  of  the  abdomen.  Abdominal  inspection  is  of  but  very  limited 
use  in  stout  individuals. 


PALPATION  519 

Position. — The  patient  lies  with  the  body  symmetrically  placed 
upon  a  firm  flat  table  with  the  hght  falUng  obliquely  from  the  head 
toward  the  foot  (see  Fig.  491).  It  is  of  advantage  when  examining  for 
ptosis  to  have  the  patient  also  assume  the  erect  position. 

Technic. — The  patient's  abdomen  being  fully  exposed,  inspection 
is  performed  from  the  side  and  from  the  foot  of  the  table  (see  Fig.  491). 
The  examiner  notes  first  the  general  appearance  of  the  abdomen, 
whether  distended  or  flat  and  whether  the  abdominal  walls  are  well 
developed  and  capable  of  supporting  the  contents.  In  enteroptosis 
the  upper  part  of  the  abdomen  is  concave  and  more  or  less  of  a  "pot- 
belly" is  evident  with  a  sulcus  between  the  two  recti  above  the  um- 
bilicus. This  characteristic  appearance  is  accentuated  with  the 
patient  in  the  erect  position — the  abdomen  appears  more  pendulous 
and  the  abdominal  contents  may  project  like  a  hernia  through  the 
space  between  the  two  recti.  The  examiner  then  makes  more  careful 
inspection  for  the  presence  of  hernia,  visible  swelling,  or  tumor.  A 
tumor  may  produce  sufficient  bulging  of  the  part  affected  to  be  recog- 
nized by  inspection.  Likewise,  if  the  individual  is  thin,  in  the  pres- 
ence of  stenosis  of  the  bowel  it  may  be  possible  to  recognize  disten- 
tion of  the  portion  of  the  bowel  proximal  to  the  seat  of  obstruction 
and  the  strong  peristaltic  waves.  Inflation  of  the  bowel  (see  page 
521)  is  of  considerable  value  in  making  more  prominent  a  tumor  or 
the  seat  of  an  obstruction. 

PALPATION 

The  cecum  and  parts  of  the  ascending,  transverse,  descending,  and 
sigmoid  colon  are  accessible  for  palpation,  depending  upon  the  stout- 
ness of  the  individual.  It  is  thus  possible  to  recognize  local  tender- 
ness, thickening  of  the  gut,  and  a  tumor,  and,  in  the  presence  of  the 
latter,  its  size,  mobility,  and  consistency. 

Preparations  of  the  Patient. — When  feasible,  the  patient's  bowels 
should  be  emptied  by  a  cathartic  given  the  night  before. 

Position. — The  examination  is  performed  with  the  patient  in  the 
dorsal  position  upon  a  flat  table  with  the  knees  flexed  and  a  small 
pillow  beneath  the  head  and  shoulders  to  secure  relaxation  of  the 
abdominal  muscles.  Shifting  the  patient  from  side  to  side  will  often 
furnish  more  complete  information  in  the  presence  of  a  tumor  or  other 
mass. 

Technic. — The  examiner  stations  himself  by  the  side  of  the  pa- 
tient and  places  his  right  hand,  well  warmed,  flat  upon  the  patient's 


520  THE  COLON  AND  RECTUM 

abdomen,  at  first  performing  gentle  circular  palpation  over  all  parts. 
Gradually  deeper  palpation  may  be  employed,  but  sudden  poking  of 
any  region  should  be  carefully  avoided.  In  performing  deep  palpa- 
tion reinforcing  one  hand  with  the  other  is  of  great  aid.  Tender 
spots,  rigidity  of  the  muscles,  and  the  presence  of  masses  should  be 
looked  for.  Tenderness  suggests  inflammation  or  ulceration  of  the 
bowel.  In  eliciting  tenderness  it  is  well  to  watch  the  patient's  face, 
as  this  is  often  a  better  guide  than  questions  as  to  his  sensations. 
Rigidity  of  one  or  both  recti  is  of  diagnostic  importance  signifying 
some  local  peritoneal  irritation  in  the  first  instance  and  general  peri- 
tonitis if  both  recti  are  involved.  A  rigid  right  rectus  is  not  uncom- 
mon, however,  in  right-sided  pneumonia  and  pleurisy.  The  sensa- 
tion a  mass  gives  to  the  palpating  hand  is  frequently  a  guide  to  its 
character.  Thus,  a  cancerous  growth  is  generally  hard  to  the  touch, 
cannot  be  indented,  and  is  frequently  uneven;  a  benign  growth  is 
generally  smooth;  a  fecal  impaction  is  movable,  has  a  doughy  feel, 
and  can  be  indented  with  the  fingers.  In  intussusception  the  mass  is 
smooth  and  has  the  characteristic  sausage  shape.  Often  more  valu- 
able information  as  to  the  source  and  mobility  of  a  mass  may  be 
elicited  by  changing  the  position  of  the  patient  from  time  to  time  and 
by  inflation  of  the  bowel  (see  page  521). 

PERCUSSION 

The  chief  use  of  percussion  is  to  confirm  the  results  obtained  by 
palpation.  The  percussion  note  over  the  empty  colon  is  tympanitic 
and  of  a  higher  pitch  and  less  volume  than  over  the  stomach,  and 
over  the  small  intestine  the  note  is  of  a  still  higher  pitch  and  less 
volume.  When  the  bowel  contains  fluid  or  fecal  matter  or  in  the 
presence  of  a  solid  tumor  the  percussion  note  is  flat.  Percussion  is 
thus  of  value  in  differentiating  between  the  empty  intestine  and  a 
solid  tumor,  and,  in  the  presence  of  the  latter,  in  determining  its  size 
and  shape.  By  first  inflating  the  bowel  with  air  or  fluid  it  is  possible 
to  trace  its  course  and  thus  recognize  the  presence  and  degree  of 
ptosis.  This  method  is  also  of  value  in  locating  the  seat  of  a  stricture 
of  the  bowel  by  the  contrast  between  the  percussion  note  obtained 
over  the  inflated  portion  and  that  over  the  empty  bowel. 

AUSCULTATION 

Auscultation  is  of  but  little  diagnostic  importance  in  diseases  of 
the  large  bowel.   Various  splashing,  gurgling,  and  whistling  sounds  are 


INFLATION    OF   THE   COLON  52 1 

to  be  heard  normally  in  the  intestines  and  are  due  to  the  movements 
of  gas  and  fluids.  In  chronic  obstruction  of  the  large  bowel  gurgling 
sounds  are  also  to  be  heard  in  the  region  of  the  obstruction,  and,  if 
they  are  always  heard  in  the  same  location,  they  are  of  considerable 
diagnostic  importance.  An  entire  absence  of  intestinal  sounds  would 
suggest  intestinal  paresis.  By  injecting  into  the  bowel  small  quanti- 
ties of  fluid  (about  a  pint  (500  c.c.))  it  is  possible  to  map  out  the  course 
of  the  bowel  by  the  splashing  sounds  heard  on  auscultation.  This 
procedure  may  be  employed  to  advantage  in  cases  of  suspected 
ptosis. 

INFLATION  OF  THE  COLON 

This  procedure  is  performed  both  as  a  diagnostic  and  as  a  thera- 
peutic measure  (for  the  latter  see  page  563).  The  bowel  may  be 
inflated  either  by  means  of  air  or  fluids.  For  diagnostic  purposes, 
however,  air  is  preferable,  as  there  is  thus  produced  a  contrast  on 
percussion  between  the  tympany  of  the  air-distended  bowel  and  the 
flatness  of  a  tumor.  It  has  the  disadvantage,  however,  that  the 
amount  injected  cannot  be  measured  as  can  fluids,  and  consequently 
the  degree  of  distention  is  not  so  well  regulated. 

The  colon  may  be  distended  as  far  as  the  cecum,  provided  there 
be  no  obstruction  and  the  inflation  be  slowly  and  carefully  performed. 
When  thus  distended,  the  bowel  is  raised  from  the  surrounding  parts 
and  is  caused  to  stand  out  against  the  abdominal  wall  so  that  it  may 
be  readily  mapped  out  by  palpation  and  by  percussion,  and  its  size, 
shape,  position,  and  mobility  may  be  determined.  It  thus  be- 
comes possible  to  locate  the  seat  of  a  stricture  or  an  obstruction  by 
noting  the  limits  of  the  distended  area — the  part  below  the  seat  of 
stenosis  becomes  prominent,  while  the  portion  of  the  bowel  above  will 
be  but  slightly  distended  or  not  at  all  so,  depending  upon  the  degree 
of  occlusion.  Under  inflation,  tumors  of  the  large  bowel  are  made 
more  prominent  and  it  is  frequently  possible  to  recognize  that  a 
growth  is  located  in  or  is  in  connection  with  the  colon  by  tracing  the 
distended  bowel  directly  into  the  tumor  mass.  Finally,  inflation  is 
also  of  great  aid  in  determining  the  probable  seat  of  other  abdominal 
tumors;  the  distention  of  the  bowel  causes  a  change  in  the  position 
of  the  tumor,  displacing  it  in  the  direction  of  the  normal  position 
of  the  organ  from  which  it  takes  origin,  so  that  tympany  is  obtained 
where  there  was  originally  dulness;  for  example,  a  tumor  of  the 
stomach  is  pushed  upward;  a  tumor  of  the  gall-bladder  and  liver  is 
pushed  upward  and  forward;  a  tumor  of  the  pancreas  becomes  less 


;22 


THE    COLON    AND    RECTUM 


noticeable;  a  tumor  of  the  kidney  is  pushed  upward  toward  the 
normal  position  of  the  kidney  and  hes  behind  the  distended  colon; 
a  tumor  of  the  spleen  will  lie  in  front  of  the  colon  and  the  growth 
will  become  more  readily  palpable  from  being  pushed  forward,  etc., 
etc. 


"^        rj]Tnini'iiir'""'i'ii'""i""i"""''i"'"""'"iMiii7ii™^™™ 
Fig.  536. — Rectal  tube  and  cautery  bulb  for  inflating  the  colon. 

Apparatus. — The  injection  of  fluids  is  effected  by  means  of  a  foun- 
tain syringe  or  a  graduated  glass  irrigating  jar  as  a  reservoir,  and 
a  rectal  tube  attached  to  the  reservoir  by  about  6  feet  (180  cm.)  of 
rubber  tubing  1/4  to  '^IZ  inch  (6  to  9  mm.)  in  diameter. 


Fig.  537. — Inflation  of  the  colon  with  oxygen.     (After  Gant.) 

For  the  injection  of  air  a  special  inflation  apparatus  may  be  em- 
ployed, but  a  rectal  tube  attached  to  a  Davidson  syringe,  cautery 
bulb  (Fig.  536),  hand  bellows,  or  bicycle  pump  will  answer  equally 
well.  The  pumping  apparatus  may  be  dispensed  \A\h  if  oxygen 
or  carbonic  gas  is  used.     In  the  case  of  the  former  the  rectal  tube 


INFLATION   or   THE    COLON  523 

is  simply  attached  to  the  oxygen  tank  (Fig.  537),  while,  if  the  latter 
gas  be  employed,  the  tube  is  attached  to  a  syphon  of  carbonic,  and 
the  latter  is  inverted  so  that  the  gas  escapes  without  the  water 
following. 

Media  for  Inflation. — Of  fluids,  warm  normal  salt  solution  (dr.  i 
(4  gm.)  of  salt  to  a  pint  (500  c.c.)  of  water)  is  best.  Air,  oxygen,  or 
carbonic  acid  gas  may  be  used  when  gaseous  distention  is  desired. 

Amount  Injected. — When  inflating  with  gas  there  is  no  way  to 
determine  accurately  the  amount  of  gas  injected,  and  the  patient's 
sensations  and  the  degree  of  distention  of  the  bowel  must  be  the 
guide.  Never  inject  sufiicient  to  cause  pain,  and  care  must  be  taken 
not  to  endanger  the  gut. 

As  much  as  3  quarts  (3  liters)  of  fluid  may  be  injected  with 
safety. 

Rapidity. — Fluid  or  gas  should  be  injected  slowly  and  steadily; 
rapid  distention  of  the  bowel  is  to  be  avoided.  From  fifteen  minutes 
to  half  an  hour  should  be  consumed  in  performing  the  operation.  If 
the  reservoir  be  not  elevated  above  3  feet  (90  cm.),  the  fluid  will  not 
enter  the  bowel  too  rapidly. 

Position  of  Patient. — The  tube  may  be  inserted  with  the  patient 
upon  his  side,  but  as  soon  as  the  inflation  is  begun  the  dorsal  position 
should  be  assumed. 

Technic. — If  there  is  any  accumulation  of  fecal  matter  in  the 
bowels  a  simple  enema  should  be  given  and  an  evacuation  produced 
before  attempting  the  operation.  The  rectal  tube  is  then  well  lubri- 
cated with  vaselin  and  is  inserted  4  or  5  inches  (10  to  12  cm.)  within 
the  rectum.  If  fluid  is  employed,  the  reservoir  is  then  elevated  be- 
tween 2  and  3  feet  (60  to  90  cm.)  and  the  solution  is  allowed  to  distend 
the  bowel  slowly,  cotton  being  tightly  packed  about  the  anus  and  the 
buttocks  being  held  in  close  apposition  to  prevent  leakage.  As  the 
rectum  becomes  distended  there  will  be  some  spasm  and  an  almost 
irresistible  desire  on  the  part  of  the  patient  to  expel  the  fluid,  but  if  the 
flow  be  temporarily  stopped,  or  the  reservoir  lowered,  and  time  be 
given  for  the  fluid  to  pass  upward,  this  feeling  soon  passes  off  and  the 
inflation  may  be  then  continued.  When  the  colon  has  been  sufficiently 
distended  and  the  purposes  of  the  examination  are  accomplished,  the 
fluid  is  allowed  to  escape  from  the  bowel  through  the  tube. 

The  technic  of  introducing  gas  is  practically  identical  with  the 
above,  great  care  being  taken,  however,  not  to  force  the  gas  in  too 
rapidly  or  in  excess,  and  at  the  completion  of  the  examination  to  draw 
off  as  much  of  it  as  possible,  so  as  to  avoid  unpleasant  distention.     Its 


524  THE  COLON  AND  RECTUM 

escape  may  be  aided  by  inserting  two  fingers  into  the  rectum  and 
holding  the  anus  open. 

SKIAGRAPHY 

The  X-rays  are  of  value  in  recognizing  the  presence  of  foreign 
bodies  in  the  intestinal  tract,  and  for  determining  the  position  of  the 
colon  and  the  seat  of  strictures,  dilatations,  angulations,  or  adhesions 
that  may  be  causing  obstruction.  For  recognizing  the  latter  condi- 
tions a  preliminary  rectal  injection  of  a  bismuth  mixture  or  the  inges- 
tion of  a  bismuth  meal  is  essential.  When  the  bismuth  is  given  by 
mouth,  its  passage  may  be  traced  through  the  intestinal  tract  by 
means  of  repeated  X-rays,  and  valuable  information  as  to  the  motil- 
ity of  the  intestinal  contents  may  be  secured. 

In  preparation  for  an  X-ray  examination  of  the  large  intestine, 
the  patient  is  given  a  purge  for  two  nights  before  and  an  enema  on 
the  day  of  the  examination  to  thoroughly  empty  the  colon.  Two 
oimces  (60  gms.)  of  bismuth  subcarbonate  are  mLxed  with  a  little 
starch  in  2  quarts  (2  liters)  of  warm  water  and  are  injected  into  the 
bowel  with  the  patient  in  the  Sims  position  with  the  hips  elevated,  or 
while  in  the  knee-chest  position,  and  a  radiograph  is  immediately 
taken;  or,  the  patient  may  be  given  by  mouth  an  ounce  (30  gms.) of 
bismuth  subcarbonate  or  oxychlorid  in  12  ounces  (360  gms.)  of  milk  or 
koumiss,  and  the  radiograph  be  taken  at  the  end  of  24  hours  when  all 
the  bismuth  should  be  in  the  large  bowel.  A  second  picture  should 
be  taken  at  the  end  of  48  hours  in  order  to  judge  of  the  motility  of 
the  bowel.  Exposures  should  be  made  with  the  patient  in  the  recum- 
bent and  in  the  upright  posture. 

//.     Internal  Examination 

Preparation  of  the  Patient. — In  order  to  make  a  satisfactory 
examination  of  the  rectum  the  latter  should  be  emptied  of  its  con- 
tents by  means  of  a  cathartic  given  the  night  before  or  by  an  enema 
administered  just  before  the  examination  is  begun.  In  some  cases, 
however,  more  useful  information  as  to  the  usual  condition  of  the 
rectum  may  be  obtained  by  making  a  preliminary  examination  of  the 
patient  in  just  the  condition  he  presents  himself.  The  presence  of 
blood,  pus,  or  mucus  will  thus  be  revealed,  of  which  there  would  often 
be  no  trace  after  a  cleansing  enema.  If  necessary,  an  enema  may 
then  be  given  and  a  more  complete  examination  may  be  made  later. 
The  bladder  should  likewise  be  evacuated,  and  tight  clothing,  such  as 


POSITIONS    FOR   INTERNAL   EXAMINATION 


525 


bands,  belts,  or  corsets,  which  tend  to  force  the  intestines  into  the 
pelvis,  should  be  loosened. 

Position  of  the  Patient. — -Four  positions  are  employed  for  rectal 
examinations,  each  of  which  has  its  own  advantages  under  special 
conditions.  These  are:  (i)  the  Sims,  (2)  the  lithotomy,  (3)  the  knee- 
chest,  and  (4)  the  squatting  posture. 

The  Sims,  or  left  lateral  position,  is  obtained  by  placing  the  pa- 
tient upon  the  left  side  with  the  left  side  of  the  face,  the  left  shoulder, 
and  the  left  breast  resting  upon  a  flat  pillow.  The  left  arm  lies  be- 
hind the  back  and  the  thighs  are  well  flexed  upon  the  body  with  the 
right  knee  drawn  up  nearer  the  body  than  the  left.  The  buttocks  lie 
near  the  edge  of  the  table  and  are  elevated  upon  a  hard  pillow  (Fig. 
538).     This  position  will  be  found  most  useful  for  routine  examina- 


FiG.  538. — The  Sims  position. 


tions,  and  probably  will  be  found  less  objectionable  to  the  patient 
than  the  lithotomy  or  knee-chest  positions. 

The  lithotomy  position  is  secured  by  placing  the  patient  flat  on  the 
back  and  flexing  the  thighs  upon  the  abdomen  and  the  legs  upon  the 
thighs.  The  buttocks,  which  are  elevated  upon  a  hard  flat  pillow, 
project  over  the  end  of  the  table  (Fig.  539) .  In  very  stout  individuals 
this  position  will  permit  of  a  more  satisfactory  examination  than  will 
the  Sims. 

The  knee-chest  position  is  obtained  by  having  the  patient  kneel 
upon  a  table  with  the  thighs  at  right  angles  to  the  legs  with  the  body 
well  flexed  upon  the  thighs,  the  chest  resting  upon  a  pillow  placed 
upon  the  same  level  as  the  knees  (Fig.  540).  The  knee-chest  position 
favors  displacement  of  the  coils  of  intestine  upward,  thus  allowing  the 
rectum  to  be  distended  by  the  entrance  of  air  upon  the  insertion  of  a 
speculum  or  proctoscope.  The  mucous  membrane  of  the  rectum, 
which  in  the  dorsal  position  lies  in  folds,  becomes  expanded,  and  thus 
a  more  thorough  inspection  of  all  portions  of  the  canal  is  possible. 


526 


THE    COLON   AND   RECTUM 


The  squatting  posture  is  only  suitable  for  digital  examination. 
The  patient  assumes  an  attitude  similar  to  that  taken  while  at  stool. 
Portions  of  the  rectum  may  be  thus  palpated  which  in  the  Sims  or  the 
dorsal  position  would  be  out  of  reach  of  the  examiner's  finger.     By  a 


Fig.  539. — The  lithotomy  position. 


'l7llll|||||||IU»l|l|l||lllllll|l|lll|ll|l||)l|l)||;|li;)||||)))||)|||||||||||)||)|,|)||i||||;|||[||||jy 

Fig.  540. — The  knee-chest  position. 

slight  straining  effort  protrusions  or  moderate  degrees  of  prolapse  will 
be  revealed. 

INSPECTION 

The  anus  is  first  inspected.  The  presence  of  discharges  from  the 
rectum,  excoriations,  eczema,  thickening  of  the  epidermis,  scars, 
ulcerations,  fistulous  openings,  condylomata,  the  swelling  of  an  abscess. 


PALPATION 


527 


and  external  hemorrhoids,  are  carefully  looked  for.  Then,  by  separ- 
ating the  buttocks  and  placing  the  thumbs  on  either  side  of  the  anus 
and  drawing  it  apart  while  the  patient  strains  slightly,  inspection  of 
the  anal  canal  for  at  least  an  inch  (2.5  cm.)  will  be  possible  (Fig.  541). 
Shght  degrees  of  prolapse,  fissures,  ulcers,  hemorrhoids,  and  polypi 
or  other  growths  may  be  readily  demonstrated  in  this  way. 


PALPATION 

Palpation  of  the  rectum  may  be  performed  by  means  of  the  finger 
or  by  the  whole  hand.  With  the  index-finger  one  may  examine  the 
anus,  the  anal  canal,  and  the  ampulla  of  the  rectum.  The  first  4 
inches  (10  cm.)  of  the  rectum  may  be  thus  explored. 


Fig.  541. — Inspection  of  the  anus.     (Ashton.) 

Introduction  of  the  whole  hand  into  the  rectum,  as  advocated  by 
Simon,  for  the  purpose  of  palpation  of  portions  of  the  canal  out  of 
reach  of  the  finger,  may  be  practised  if  the  hand  is  moderately  small. 
Tuttle  states  that  a  hand  requiring  a  kid  glove  larger  than  73/4  should 
never  be  introduced  into  the  rectum  except  in  a  life  or  death  emer- 
gency. Manual  palpation  is  rarely  required,  being  only  necessary  for 
examining  tumors  high  up  that  cannot  be  inspected  by  means  of  a 
speculum  or  a  proctoscope.  In  addition,  it  is  a  serious  procedure,  as 
there  is  danger  of  rupture  or  undue  distention  of  the  bowel  in  careless 
hands. 

Anesthesia. — General  anesthesia  will  be  required  for  palpation  by 
the  whole  hand,  as  complete  dilatation  of  the  rectum  is  essential. 


528 


THE    COLON   AND   RECTUM 


Technic. — i .  By  the  Finger. — No  anesthesia  will  be  required.  The 
direction  of  the  rectum,  which  is  at  first  slightly  forward  from  the 
anus,  then  back  into  the  hollow  of  the  sacrum,  then  to  the  right,  and 
finally  to  the  left  toward  the  sigmoid  flexure,  should  be  kept  clearly  in 
mind.  The  index-finger  of  the  right  hand  is  covered  with  a  rubber 
finger  cot.  If,  however,  it  is  desired  to  preserve  the  tactile  sense  of 
the  finger,  a  covering  is  dispensed  with,  in  which  case  soap  should  be 
forced  under  the  nail.  The  finger  is  well  lubricated  with  sterile  vase- 
lin  or  with  one  of  the  preparations  of  Irish  moss  made  for  the  pur- 
pose and  is  then  introduced  slowly  and  with  a  rotary  motion,  the 


Fig.  542. — Palpation  of  the  rectum.     (Gant.) 


patient  being  requested  to  strain  gently  to  f  acihtateits  passage  through 
the  sphincter.  Roughness  in  inserting  the  finger  or  disregard  of  the 
natural  direction  of  the  canal  will  be  liable  to  cause  spasm  of  the 
sphincter  and  give  the  patient  such  pain  that  a  thorough  examination 
will  be  impossible. 

As  the  finger  passes  through  the  anal  canal  the  condition  of  the 
sphincter  should  be  noted,  the  examiner  observing  whether  it  is  closed, 
rigid,  and  resisting,  or  loose  and  patulous.  When  the  internal  sphinc- 
ter has  been  passed,  the  finger  is  swept  lightly  over  the  mucous  mem- 
brane, palpating  the  rectal  wall  in  all  directions.  The  size  and  sensi- 
tiveness of  the  rectum  is  thus  ascertained.  The  examining  finger  will 
readily  detect  the  presence  of  impacted  feces,  polypi,  large  hemor- 
rhoids, malignant  growths,  ulcerations,  fissures,  and  strictures  if  a 
systematic  examination  is  made.  In  the  male,  enlargement,  indura- 
tion, degrees  of  sensitiveness,  or  softness  of  the  prostate  should  be 


PALPATION 


529 


carefully  noted,  and  likewise  information  regarding  the  condition  of 
the  seminal  vesicles  and  bladder  should  be  obtained.  A  vesical  cal- 
culus may  frequently  be  discovered  by  such  examination.  In  the 
female,  the  uterus,  tubes,  ovaries,  and  broad  ligaments  are  carefully 
examined  for  displacements  or  signs  of  inflammation.     Finally,  the 


Fig.  543. — Method  of  dilating  the  anus  by  means  of  one  finger  of  each  hand. 

coccyx  should  not  be  overlooked,  as  this  bone  may  be  responsible  for 
considerable  rectal  disturbance. 

If  pus,  blood,  or  mucus  be  present  in  the  bowel  there  will  be  an 
escape  of  the  material  from  the  anus  when  the  finger  is  withdrawn  or 
the  finger  will  come  away  coated.     In  all  cases  it  is  important  to  note 


Fig.  544. — Method  of  dilating  the  anus  by  means  of  two  fingers  of  each  hand. 

the  odor  of  the  examining  finger  upon  its  withdrawal.  The  foul  odor 
of  cancer  is  characteristic  and  will  not  be  mistaken  for  anything 
else  once  it  is  recognized. 

2.  By  the  Whole  Hand. — Stretching  of  the  sphincters  is  commenced 
by  introducing  into  the  anus  the  two  forefingers  with  the  palmar  sur- 

34 


530 


THE    COLON    AND    RECTUM 


faces  out,  and  separating  them  slowly  and  gently  in  all  directions,  care 
being  taken  to  avoid  injury  to  the  mucous  membrane  if  possible 
(Fig.  543).  As  soon  as  a  little  dilatation  has  been  secured,  two  and 
then  three  fingers  of  each  hand  may  be  introduced,  carrying  them  to  a 
point  well  above  the  internal  sphincter.  The  lingers  are  then  gradu- 
ally separated  imtil  sufl&cient  dilatation  is  obtained  to  allow  the  hand 
to  pass  (Fig.  544).  The  hand  is  then  well  lubricated  and.  with  the 
fingers  formed  in  the  shape  of  a  cone,  it  is  gradually  introduced  past 
the  sphincter  muscles  until  it  enters  the  dilated  ampulla.  From 
this  point  on  only  two  fingers  should  be  used  in  palpation,  and  great 
care  and  gentleness  are  necessary  to  prevent  injury,  as  the  canal 
gradually  narrows  down. 

EXAMINATION  BY  THE  SPECULUM  OR  PROCTOSCOPE 

By  the  aid  of  suitable  specula  and  reflected  Ught,  the  whole  inner 
surface  of  the  rectum  up  to  the  sigmoid  flexure  may  be  inspected. 
The  openings  of  glands  and  the  condition  of  the  valves  and  any  altera- 
tion in  color  or  unevenness  of  the  surface  of  the  mucous  membrane 


Fig.  545. — The  Sims  rectal  speculum.     (Hirst.) 


are  noted.  Ulcers,  polypi,  new  growths,  malignant  disease,  stric- 
tures, the  internal  openings  of  fistulous  tracts,  hemorrhoids,  and 
congestion  or  inflammation  of  the  rectal  mucosa  may  be  distin- 
guished by  the  experienced  examiner. 

Instruments. — The  ordinary  rectal  specula  are  made  in  various 
shapes  and  styles,  such  as  the  Sims  (Fig.  545),  the  bivalve,  the  duck- 
bill (Fig.  546),  the  fenestrated-blade  (Fig.  547),  the  conical,  etc. 
These  are  all  useful  instruments  for  inspection  of  the  lower  4  or  5 


EXAMINATION  BY   THE    SPECULUM   OR   PROCTOSCOPE 


531 


inches  (10  to  12  cm.)  of  the  bowel,  but  their  usefulness  is  limited  to 
that  region. 

For  examination  of  points  higher  up  Kelly  has  devised  a  set  of 
tubular  specula  (Fig.  548)  which  permit  a  thorough  inspection  of  the 
whole  rectum  and  the  sigmoid  flexure.  This  set  of  instruments  con- 
sists of:  (i)  a  sphincteroscope,  (2)  a  long  and  (3)  a  short  proctoscope, 
and  (4)  a  sigmoidoscope.  The  sphincteroscope  is  short  and  slightly 
conical;  the  diameter  of  the  lower  end  of  the  tube  is  i  inch  (2.5  cm.) 
and  of  the  upper  end  i  1/5  inches  (3  cm.).     The  cylinder  of  the  short 


Fig.  546. — Duck-bill  rectal  speculum. 


Fig.  547. — Fenestrated-blade  rectal 
speculum. 


proctoscope  is  5  1/2  inches  (14  cm.)  long,  and  7/8  inch  (22  mm.)  in 
diameter.  The  long  proctoscope  is  8  inches  (20  cm.)  long  and  of  the 
same  diameter  as  the  short  proctoscope,  and  the  sigmoidoscope  is  of 
like  diameter  and  14  inches  (35  cm.)  long.  Each  speculum  consists 
of  a  cylindrical  metal  tube,  at  the  outer  end  of  which  is  a  funnel-shaped 
rim  about  2  inches  (5  cm.)  in  diameter  to  which  a  handle  is  attached. 
A  blunt  obturator  is  provided  to  facilitate  the  introduction  of  the 
instrument  into  the  bowel.  Illumination  is  secured  from  an  electric 
light  held  close  to  the  sacrum,  which  is  reflected  by  a  head  mirror  into 
the  speculum,  or  else  an  electric  head  light  or  the  direct  sunlight  may 
be  employed. 


532 


THE    COLON    AND    RECTUM 


Murphy  has  modified  Kelly's  instrument  in  such  a  way  that  the 
specula  telescope,  the  proctoscope  fitting  into  the  sphincteroscope, 
etc.  This  does  away  with  the  necessity  of  withdrawing  and  inserting 
a  speculum  through  the  anus  each  time  a  smaller  size  is  used.  The 
sphincteroscope  is  used  first,  and  into  this  the  next  smaller  size  is 
passed  without  withdrawing  the  original  instrument,  until  all  have 
been  introduced  in  succession. 


Fig.  548. — Kelly's  set   of   tubular  specula,      i,  Swab  and  holder;    2,  sigmoido- 
scope; 3,  long  proctoscope;  4,  short  proctoscope;  5,  sphincteroscope. 


The  pneumatic  proctoscope,  such  as  Tuttle's  modification  of 
Law's  instrument  (Fig.  549)  is  not  dependent  upon  atmospheric 
pressure  as  a  means  of  dilatation,  this  being  accomplished  by  a  special 
inflation  apparatus  connected  with  the  instrument.  Tuttle's  procto- 
scope consists  of  a  long  cylinder,  to  the  circumference  of  which  is 
fitted  a  small  metallic  tube  closed  at  its  distal  extremity  bv  a  flint-glass 
bulb.  An  electric  light  fitted  upon  a  long  metallic  stem  is  carried 
through  the  small  accessory  cylinder  to  the  end  of  the  speculum.  An 
obturator  fits  into  the  distal  end  of  the  large  cylinder  to  facilitate  the 
introduction  of  the  instrument.  In  addition,  there  is  an  air-tight- 
fitting  plug  containing  either  a  plain  glass  window  or  a  lens  focused  to 
the  length  of  the  instrument  to  be  inserted  in  the  proctoscope  when 
the  obturator  is  removed.  This  plug  is  in  connection  with  an  in- 
flating apparatus.  An  adjustable  handle  is  supplied  with  the  instru- 
ment. These  specula  vary  in  length  from  4  to  14  inches  (10  to  35 
cm.).  Tuttle  recommends  a  4-  and  a  lo-inch  (10  and  25  cm.)  tube 
for  ordinary  use.     The  light  is  furnished  by  a  four  or  a  six  dry-cell 


EXAMINATION  BY    THE    SPECULUM    OR   PROCTOSCOPE 


53S 


battery.     In  using  the  specula  and  proctoscope  long  dressing  forceps 
and  cotton  balls  with  which  to  swab  out  the  bowel  will  be  required. 
Asepsis. — The  specula  may  be'  sterilized  by  boiling  or  by  im- 
mersion in  a  I  to  20  carbolic  acid  solution.     In  case  the  latter  is 


Fig.  549. — Tuttle's  pneumatic  proctoscope,  i,  Proctoscope  with  obturator 
removed;  2,  obturator;  3,  handle;  4,  air-tight  plug  with  glass  window;  5,  inflating 
apparatus. 

employed,  the  instrument  should  be  rinsed  off  with  alcohol  or  sterile 
water  before  use. 

Position  of  the  Patient. — In  employing  the  ordinary  proctoscope, 
the  patient  should  be  placed  in  the  knee-chest  position,  so  that  the 


FiG.  550. — Method  of  holding  the  proctoscope. 


rectum  will  balloon  up  upon  the  entrance  of  air  through  the  instru- 
ment. When  using  the  pneumatic  proctoscope,  which  does  not 
depend  upon  atmospheric  pressure  for  inflation,  the  Sims  position 
may  be  employed  instead  of  the  knee-chest,  if  desired. 


534 


THE   COLON   AND   RECTUM 


Anesthesia. — An  anesthetic  is  not  required,  as  a  rule,  unless  the 
patient  is  extremely  hyperesthetic. 

Technic. — i.  With  the  Kelly  Instrument. — The  instrument  should 
always  be  warmed  and  lubricated  with  sterile  vaselin  before  its 


Fig.  551. — Proctoscopy.     First  step,  method  of  inserting  the  instrument. 


Fig.  552. — Proctoscopy.     Second  step,  showing  the  direction  of  the  instrument 
in  passing  through  the  anus. 

introduction.  In  using  the  sphincteroscope  the  handle  of  the  instru- 
ment is  grasped  in  the  right  hand  with  the  right  thumb  pressing 
against  the  obturator,  as  shown  in  Fig.  550.  The  buttocks  are  then 
drawn  apart  and,  with  the  end  of  the  obturator  held  against  the  anal 


EXAMINATION  BY   THE   SPECULUM   OR  PROCTOSCOPE  535 

orifice,  tlie  patient  strains  slightly  and  the  speculum  is  slowly  pushed 
into  the  bowel  in  a  direction  downward  and  forward  until  the  funnel- 
shaped  rim  prevents  its  further  progress.  The  obturator  is  then  re- 
moved, allowing  air  to  pass  in  and  distend  the  bowel.     The  light 


Fig.  553. — Proctoscopy.     Third  step,  showing  the  direction  of  the  instrument  in 

entering  the  ampulla. 


Fig.  554. — Proctoscopy.     Fourth  step,  showing  the  instrument  inserted  to  its 

full  extent. 

is  reflected  into  the  instrument  in  such  a  way  as  to  thoroughly  illumi- 
nate the  interior,  and,  as  the  instrument  is  slowly  withdrawn,  the 
whole  of  the  anal  canal  is  carefully  inspected. 

The  proctoscope  is  inserted  in  precisely  the  same  manner,  first 


536 


THE    COLON   AND   RECTUM 


pushing  the  instrument  in  a  direction  downward  and  forward  (Fig. 
552)  and  then  upward  toward  the  sacral  hollow  (Fig.  553).  As  soon 
as  the  tube  enters  the  ampulla,  the  obturator  should  be  withdrawn 
allowing  air  to  enter  and  expand  the  bowel.  The  light  is  then  thrown 
into  the  instrument  and  the  ampulla  is  inspected.  From  this  point 
the  instrument  is  advanced  past  the  valves  entirely  by  sight.  Some 
diQiculty  may  be  experienced  in  following  the  direction  of  the  canal 
from  a  valve  or  fold  of  mucous  membrane  occluding  the  end  of  the 
instrument.     In  such  a  case  the  distal  end  of  the  instrument  should  be 


Fig.  555. — Showing  the  method  of  performing  proctoscopy  by  the  aid  of  a  head 
mirror  and  an  electric  Hght. 


gently  moved  from  side  to  side  until  the  opening  of  the  canal  is  found. 
In  this  manner  the  whole  interior  of  the  rectum  may  be  inspected. 
As  the  instrument  is  withdrawn,  the  condition  and  character  of  the 
mucous  membrane  as  it  falls  over  the  end  of  the  instrument  is  noted 

(Fig.  555)- 

In  introducing  the  sigmoidoscope  it  is  to  be  remembered  that  the 
upper  portion  of  the  canal  gradually  turns  to  the  left,  hence  the  point 
of  the  instrument  is  turned  in  that  direction  as  it  slowly  ascends  the 
bowel. 

2.  With  Tuttle's  Proctoscope. — The  proctoscope,  warmed  and  well 
lubricated,  is  introduced  in  much  the  same  manner  as  is  Kelly's 
instrument.  To  avoid  causing  the  patient  any  discomfort  from  the 
presence  of  the  auxiliary  tube,  however,  it  is  well  to  insert  the  index- 
finger  of  the  left  hand  into  the  bowel  first  and  then  to  introduce  the 
instrument  with  the  end  of  the  auxiliary  tube  pressed  against  the 


EXAMINATION  BY    SOUNDS   AND  BOUGIES 


537 


finger  (Fig.  556) ;  as  the  tube  enters  the  bowel  the  finger  is  withdrawn. 
When  the  internal  sphincter  has  been  passed,  the  obturator  is  with- 
drawn and  the  plug  containing  the  glass  lens  is  substituted.  This 
makes  the  instrument  air-tight.  Pressure  upon  the  bulb  of  the  in- 
flating apparatus  distends  and  straightens  out  the  canal  as  the  instru- 
ment is  advanced.  Should  the  lamp  become  obscured  by  feces  or 
mucus,  the  plug  is  removed  from  the  instrument  and,  without  re- 


FiG.  556. — Showing  the  method  of  inserting  Tuttle's  instrument  with  the  finger  in 
the  rectum  and  the  auxiliary  tube  pressing  against  it. 

moving  the  instrument,  the  glass  is  wiped  off  with  a  cotton  wipe  held 
in  long  dressing  forceps.  At  the  completion  of  the  examination  the 
cap  at  the  end  of  the  tube  is  withdrawn  and  the  air  is  allowed  to 
escape  from  the  bowel  before  the  instrument  is  removed. 

EXAMINATION  BY  SOUNDS  AND  BOUGIES 

The  employment  of  the  rectal  sound  or  bougie  for  the  diagnosis  of 
stricture  has  been  superseded  to  a  large  extent  by  the  use  of  the  proc- 
toscope. The  bougie,  furthermore,  is  not  a  very  reliable  instrument, 
as  strictures  that  do  not  exist  may  be  imagined  to  be  present  from  the 
point  of  the  instrument  catching  in  the  folds  of  mucous  membrane  or 
in  a  diverticulum,  or  from  being  arrested  by  fecal  matter,  the  prom- 
ontory of  the  sacrum,  a  retroverted  uterus,  or  an  enlarged  prostate. 
Again,  the  instrument  may  bend  or  curve  upon  itself. 

Instruments. — There  are  many  varieties  of  sounds  and  bougies 
made  for  diagnostic  purposes,  but  the  only  instrument  that  should  be 


538 


THE    COLON   AND   RECTUM 


employed  is  a  soft-rubber  one,  the  Wales  bougie  (Fig.  557)  being  a 
type.  Metal  or  hard-rubber  sounds  are  dangerous,  even  in  the  hands 
of  an  expert,  unless  they  are  inserted  by  the  aid  of  a  proctoscope, 
as  they  may  easily  be  pushed  through  the  rectal  wall  into  the  peri- 
toneal cavity,  especially  if  the  rectum  is  weakened  by  some  patho- 
logical condition.  The  Wales  bougie  is  made  of  soft  rubber  in 
different  sizes,  and  in  length  measures  about  12  to  14  inches  (30  to  35 
cm.).  It  is  perforated  by  a  canal  running  through  its  center  for  the 
purpose  of  allowing  fluid  to  be  injected  into  the  bowel  to  aid  in  its 
passage.  In  using  this  instrument  a  Davidson  syringe  should  be 
provided. 


!_JL 


O    C^ 


Fig.  557. — Wales'  bougies. 

Technic. — The  bougie,  well  lubricated,  is  gently  inserted  into  the 
bowel  until  its  further  progress  is  impeded  by  some  obstruction. 
The  Davidson  syringe  is  then  attached  and  a  stream  of  warm  water  or 
oil  is  forced  through  the  instrument  for  the  purpose  of  dislodging  any 
fecal  matter  or  folds  of  mucous  membrane  that  may  be  interfering 
with  its  passage.  In  this  way  the  whole  length  of  the  bowel  may  be 
explored  without  danger,  and  the  instrument  may  be  passed  into  the 
sigmoid  provided  no  stricture  exists. 

EXAMINATION  BY  THE  BOUGIE  A  BOULE 

The  rectal  bougie  a  boule  is  made  use  of  in  diagnosis  to  determine 
the  size  and  length  of  a  stricture. 


Fig.  558. — Rectal  bougie  a  boule. 

Instruments. — The  bougie  a  boule  consists  of  a  flexible  wire  or 
rubber  shaft  with  a  handle  to  the  extremity  of  which  acorn-tips  of 
various  sizes  may  be  screwed  (Fig.  558).     The  bougie  a  boule  is  used 


EXAMINATION   BY    THE    PROBE 


539 


to  best  advantage  in  connection  with  a  cylindrical  speculum  or  a 
proctoscope. 

Technic. — A  speculum  is  introduced  into  the  anus  and  is  carried 
up  to  the  seat  of  the  stricture  so  that  a  clear  view  of  its  opening  may 
be  secured.  The  examiner  begins  by  selecting  a  large  bougie  and 
passing  it  through  the  speculum  to  the  opening  in  the  stricture  (Fig. 
559).  If  it  is  found  to  be  too  large  to  enter  the  stricture,  smaller 
instruments  are  selected  until  one  is  found  that  will  just  pass  through 
the  contracture.     This  is  inserted  entirely  through  the  stricture,  using 


Fig.  559.  Fig.  560. 

Fig.  559. — Method  of  estimating  the  length  of  a  rectal  stricture,  the  bougie  a 
boule  at  the  face  of  the  stricture. 

Fig.  560. — Method  of  estimating  the  length  of  a  rectal  stricture.  The  bougie 
k  boule  is  withdrawn  until  its  base  is  arrested  at  the  distal  end  of  the  stricture. 


gentleness  only  in  manipulation,  and  as  it  is  withdrawn  its  base 
catches  the  distal  opening  of  the  stricture  (Fig.  560).  From  this  ex- 
amination the  exact  length  and  size  of  the  contracture  may  be  readily 
ascertained. 

EXAMINATION  BY  THE  PROBE 

Probing  has  but  little  utihty  in  the  diagnosis  of  rectal  diseases 
except  as  a  means  of  determining  the  situation  and  course  of  a  recto- 
vaginal or  ischiorectal  fistula. 

Instruments. — A  silver  probe  8  or  10  inches  (20  to  25  cm.)  long 


540 


THE   COLON   AND   RECTUM 


with  a  flat  handle  is  employed  (Fig.  561).  The  probe  should  be  flex- 
ible that  it  may  be  bent  in  any  direction  if  desired.  When  examining 
for  a  recto-vaginal  fistula  a  Sims  speculum  will  be  required  in  addition 
to  expose  the  fistulous  opening  in  the  vagina. 


Fig.  561. — Rectal  probe. 

Technic. — The  index-finger  of  the  left  hand,  well  lubricated,  is 
first  introduced  into  the  rectum.  The  probe,  grasped  in  the  right 
hand,  is  then  passed  through  the  external  opening  in  the  supposed 
direction  of  the  fistulous  tract.  The  tract  of  the  sinus  is  thus  slowly 
explored,  removing  the  probe  and  bending  it  so  as  to  alter  its  shape  to 
correspond  with  the  direction  of  the  sinus  if  necessary.  The  internal 
finger  at  once  recognizes  the  tip  of  the  probe  as  it  enters  the  rectum 
(Fig.  562). 


Fig.  562. — Showing  the  method  of  probing  an  ischiorectal  fistula.     (Ashton.) 

LAVAGE  OF  THE  BOWEL 

As  a  diagnostic  measure,  irrigation  of  the  bowel  is  sometimes 
employed  for  the  purpose  of  securing  samples  of  the  contents  for 
examination.  The  presence  of  blood,  pus,  amebae,  tumor  fragments, 
etc.,  in  the  material  thus  obtained,  will  often  lead  to  the  recognition 
of  ulcerative  or  suppurative  processes  or  malignant  conditions  which 
from  their  location  high  up  in  the  bowel  might  otherwise  escape 
notice. 


EXAMINATION    OF   THE    FECES  54 1 

Apparatus. — There  will  be  required  a  rectal  tube  connected  with 
a  glass  funnel  by  about  3  feet  (90  cm.)  of  rubber  tubing. 

Position  of  the  Patient. — Irrigation  may  be  performed  with  the 
patient  in  the  dorsal  position  or  lying  upon  the  left  side  with  the 
knees  drawn  up. 

Technic. — The  tube,  properly  lubricated,  is  inserted  into  the  rec- 
tum a  short  distance,  and  about  a  pint  (500  c.c.)  of  warm  boiled 
water  is  slowly  allowed  to  run  into  the  bowel  through  the  funnel, 
which  is  elevated  i  to  2  feet  (30  to  90  cm.)  above  the  level  of  the 
patient.  As  soon  as  any  discomfort  is  felt  by  the  patient,  the  funnel 
is  lowered  and  the  contents  of  the  bowel  are  syphoned  off  and  pre- 
served for  examination. 

EXAMINATION  OF  THE  FECES 

Examination  of  the  stools  is  of  distinct  diagnostic  value  in  many 
of  the  diseases'of  the  digestive  tract.  Besides  furnishing  information 
as  to  the  functional  activity  of  the  various  organs  associated  with  the 
process  of  digestion  and  absorption  of  food,  it  is  a  valuable  aid  in 
the  recognition  of  those  diseases  of  the  rectum  and  large  intestine 
which  are  due  to  infection  by  parasites  and  bacteria.  Without 
attempting  to  enter  into  the  technic  of  such  examination,  the  details 
of  which  will  be  found  fully  described  in  manuals  on  clinical  labora- 
tory methods,  the  lines  along  which  the  investigation  should  be 
conducted  may  be  briefly  referred  to.  There  are  four  methods  of 
examination  available:  macroscopical,  microscopical,  chemical,  and 
bacteriological. 

Macroscopical  examination. — The  amount,  color,  odor,  consistency, 
and  form  of  the  stool  and  the  presence  or  absence  of  mucus,  blood,  or 
pus  should  be  carefully  noted. 

Microscopical  examination  is  made  for  the  purpose  of  detecting 
intestinal  parasites  or  their  ova,  fat  globules,  undigested  meat  fibers, 
blood,  pus,  or  tumor  fragments. 

Bacteriological  examination  will  identify  pathogenic  bacteria  if 
present. 

Chemical  examination  should  include  tests  for  mucin,  albumin, 
carbohydrates,  fat,  blood,  bile  pigments,  etc. 

Therapeutic  Measures 
ENEMATA  AND  ENTEROCLYSIS 

Hydrotherapy  of  the  lower  bowel  may  be  carried  out  by  means  of 
enemata  or  by  enteroclysis.     These  two  measures  are  often  unneces- 


542  THE    COLON   AND   RECTUM 

sarily  confused  and,  while  in  general  they  are  employed  for  the  relief 
of  much  the  same  conditions,  yet  in  practical  application  they  are 
quite  distinct.  By  an  enema  is  understood  the  introduction  into  the 
bowel  of  clysters  of  fluid  to  be  retained  some  little  time  at  least.  The 
quantity  of  fluid  so  injected  is  usually  small  in  amount,  rarely  ex- 
ceeding I  or  2  pints  (500  to  1000  ex.).  Enteroclysis,  on  the  other 
hand,  is  an  irrigation  of  the  lower  bowel,  the  fluid  returning  almost 
as  rapidly  as  it  is  introduced.  In  this  procedure,  large  quantities 
of  fluid  are  made  use  of — frequently  several  gallons  at  an  irrigation. 
The  enema  and  the  irrigation  may  both  be  administered  either  low 
or  high,  according  to  whether  the  fluid  is  introduced  a  few  inches  up 
the  rectum  or  high  in  the  colon. 

Enemata. — Enemata  may  be  of  several  kinds,  according  to  the 
purpose  for  which  they  are  employed.  They  may  be  designed 
simply  to  secure  an  action  of  the  bowels  in  ordinary  constipation  or  to 
unload  the  bowel  of  long-standing  fecal  accumulations  or  impactions 
and  at  the  same  time  relieve  the  accompanying  tympanites.  These 
are  known  as  purgative  enemata.  Such  injections  owe  their  action  to 
the  stimulating  eft'ects  upon  intestinal  peristalsis  and  to  the  softening 
produced  in  the  hardened  fecal  matter.  In  the  treatment  of  consti- 
pation, however,  the  use  of  enemata  should  be  restricted  as  much  as 
possible;  they  should  not  be  advised  for  long-continued  use,  as  they 
gradually  lose  their  potency,  and  constantly  increasing  quantities  are 
necessary  to  produce  an  efi'ect.  For  the  local  effects  in  colitis,  dysen- 
tery, catarrhal  and  ulcerative  conditions  of  the  rectum  and  colon, 
small  enemata  of  antiseptic,  astringent,  or  sedative  solutions  to  be 
retained  some  little  time  are  administered  after  each  movement  or 
following  a  cleansing  irrigation.  While  used  mainly  for  purgative 
and  cleansing  effects,  enemata  have  other  valuable  uses  in  thera- 
peutics. Rectal  injections  of  saline  solution  are  made  use  of  in  the 
treatment  of  shock,  hemorrhage,  sepsis,  etc.  (see  Saline  Infusions, 
p.  554).  Rectal  enemata  are  likewise  employed  as  a  means  of  intro- 
ducing fluids  and  nutriment  into  the  bowel  (see  Rectal  Feeding, 
p.  560)  and  for  the  administration  of  drugs  which  affect  the  general 
system  after  absorption. 

In  employing  the  rectum  as  an  avenue  for  the  administration  of 
drugs,  however,  certain  facts  are  to  be  kept  in  mind.  The  drug 
should  always  be  given  in  such  a  state  that  the  active  principle  is  in  an 
aqueous  solution  or  else  is  capable  of  being  dissolved  in  the  fluids  of 
the  rectum.  It  should  also  be  remembered  that,  while  the  absorption 
power  of  the  rectum  may  be  great,  drugs  are  taken  up  but  slowly  and 


ENEMATA   AND   ENTEROCLYSIS 


543 


if  a  rapid  effect  is  desired,  this  method  should  not  be  employed.  As  a 
rule,  unless  the  drug  is  very  powerful  and  is  capable  of  being  rapidly 
absorbed,  the  dose  is  twice  the  amount  given  by  mouth. 

Apparatus. — The  simpler  the  apparatus,  provided  it  is  efficient, 
the  better.  A  fountain  syringe  or  a  glass  irrigating  jar,  capable  of 
holding  a  quart  (looo  c.c.)  of  solution,  will  be  required  as  a  reservoir, 
but  in  an  emergency  a  large  funnel  will  answer.  A  rubber  tubing 
about  1/4  to  3/8  inch  (6  to  9  mm.)  in  diameter  and  at  least  6  feet 
(180  cm.)  long  is  connected  with  the  outlet  of  the  reservoir,  and  to  the 


Fig.  563. — Fountain  syringe  and  nozzle 
for  giving  a  low  enema. 


Fig.  564. — Colon  tube  and  funnel. 


free  end  an  approximate  nozzle  is  attached  (Fig.  563).  For  low 
enemata  the  ordinary  hard-rubber  rectal  nozzle  provided  with  every 
douche-bag  will  answer,  but  if  the  injection  is  to  be  given  high  up  in 
the  bowel  a  flexible-rubber  rectal  tube  about  20  inches  (50  cm.)  long 
will  be  more  convenient.  The  tube  should  be  smooth  and  from  t,/^ 
to  1/2  inch  (9  to  12  mm.)  in  diameter.  A  very  simple  apparatus 
consists  of  a  long  colon  tube  and  a  funnel  (Fig.  564). 

Rectal  tubes  are  made  with  the  openings  at  the  side,  or  with  one 
opening  at  the  end  (Fig.  565) .  The  latter  are  better,  as  the  fluid  may 
be  injected  directly  through  the  tube  for  the  purpose  of  dislodging 
any  feces  or  folds  of  mucous  membrane  that  may  obstruct  the  pas- 


544  THE  COLON  AND  RECTUM 

sage  of  the  tube.     In  addition,  a  bed-pan  or  a  douche-pan  should  be 
provided. 

Formulary.— For  simple  cleansing  purposes  or  to  produce  an 
evacuation  in  mild  cases  of  costiveness  an  enema  consisting  of  normal 
salt  solution  (dr.  i  (4  gm.)  of  salt  to  i  pint  (500  c.c.)  of  warm  water) 
or  the  soap-suds  enema,  made  b}^  adding  to  i  quart  (1000  c.c.)  of 


II"""""""""""'"" ''''"•^iiiiiiiiti^TuiTmr"'""''^ — — - — ■■  --'--> 

Fig.  565. — Rectal  tubes. 

hot  water  sufficient  castile  soap  scrapings  to  make  suds,  may  be  used. 
The  continued  use  of  the  latter  is  not  advisable,  however,  as  some 
irritation  may  be  caused  by  the  lye  which  is  apt  to  result  in  proctitis 
or  skin  eruptions. 

In  habitual  constipation  the  injection  of  from  2  to  6  ounces  (60  to 
180  c.c.)  of  warm  sweet  oil  into  the  bowel  or  the  use  of  the  flax-seed 
enema  will  often  give  good  results.  The  latter  is  prepared  by  adding 
I  ounce  (30  gm.)  of  flax-seed  to  i  pint  (500  c.c.)  of  cold  water  and 
then  boiling  the  mixture  for  ten  minutes.  The  resulting  muci- 
laginous mixture  is  strained  and  injected  while  warm.  Another 
good  enema  consists  of  equal  parts  of  milk  and  molasses.  When 
a  more  profound  effect  is  desired  there  are  a  number  of  drugs  that 
may  be  incorporated  in  the  enema.  Of  these  may  be  mentioned 
olive  oil,  castor  oil,  glycerin,  ox  gall,  turpentine,  magnesium  sulphate, 
Carlsbad  salt,  etc.  The  following  combinations  of  the  above  will 
be  found  useful: 

I^  Olive  oil  or  castor  oil,  oz.  ii  (60  c.c.) 

Warm  soapy  water,  oz.  iv  (120   c.c.) 

I^  Glycerin,  oz.  i  (30  c.c.) 

Olive  oil.  oz.  iii  (90  c.c.) 

Warm  soapy  water,  oz.  iv  (120  c.c.) 

I^  Ox  gall,  dr.  ii  (8  gm.) 

Warm  water,  O    i  (500  c.c.) 

I^  Ox  gall,  dr.  ii    (8  gm). 

Glycerin,  oz.  iv  (120  c.c.) 

Warm  water,  O    i  (500  c.c.) 


ENEMATA  AND   ENTEROCLYSIS  545 

I^  Magnesium  sulphate,  oz.  i  (30  gm.) 

Glycerin,  oz.  ii  (60  c.c.) 

Warm  water,  oz.  iii  (90  c.c.) 

I^  White  of  egg  (beaten), 

Oil  of  turpentine,  dr.  i  (4  c.c.) 

Olive  oil,  oz.  i  (30  c.c.) 

Warm  water,  O    i  (500  c.c.) 

I^  Magnesium  sulphate,  oz.  ii  (60  gm.) 

Oil  of  turpentine,  dr.  ii  (8  c.c.) 

Glycerin,  oz.  ii  (60  c.c.) 

Warm  water,  oz.  iv  (120  c.c.) 


For  the  relief  of  t^onpanites  a  turpentine  enema  or  an  enema  con- 
sisting of  3  ounces  (90  c.c.)  of  milk  of  asafetida  may  be  used.  For 
irritability  of  the  rectum  the  use  of  a  small  flaxseed  enema  or  the 
starch-water  enema,  to  which  10  to  2oTn,  (0.6  to  1.25  c.c.)  of  laudanum 
are  added,  will  often  give  great  rehef.  The  starch-water  enema  is 
prepared  by  adding  to  an  ounce  (30  gm.)  of  starch  suflicient  cold 
water  to  form  a  thick  paste;  enough  boiling  water  is  then  added  to 
dilute  this  mixture  to  the  consistency  of  mucilage. 

Temperature.^ — The  enema  should  be  given  warm — at  a  tempera- 
ture of  about  100°  F.  (38°  C.) — unless  contraindicated. 

Rapidity  of  Flow. — The  solution  should  always  be  injected  slowly 
to  avoid  discomfort  and  spasm  from  a  sudden  distention  of  the  bowel. 
The  reservoir  is  consequently  elevated  2  to  3  feet  (60  to  90  cm.) 
above  the  patient. 

Quantity. — To  stimulate  peristalsis  and  produce  an  evacuation 
of  the  bowels  a  bulk  of  liquid  sufiiciently  large  to  distend  the  walls  of 
the  intestine  should  be  injected.  For  this  purpose  between  i  pint 
(500  c.c.)  and  i  quart  (1000  c.c.)  of  fluid  is  made  use  of  at  one  injec- 
tion. Enemata  to  be  permanently  retained  for  absorption,  such  as 
those  containing  drugs  or  nutriment,  should  be  small  in  amount,  as  a 
rule  containing  only  2  or  3  ounces  (60  to  90  c.c.)  of  fluid. 

Position  of  the  Patient. — The  dorsal,  the  Sims,  or  the  knee-chest 
position  may  be  utilized.  In  the  case  of  the  two  former  the  hips 
should  be  elevated  upon  a  hard  pillow;  especially  is  this  necessary  if 
the  enema  is  to  be  injected  high  into  the  bowel.  Infants  can  be  best 
controlled  when  placed  upon  the  attendant's  lap,  lying  upon  the  back. 

Technic. — The  tube  is  first  well  lubricated  with  vaselin,  and  any 
air  is  expelled.  The  left  hand  then  separates  the  buttocks,  and, 
while  the  patient  strains  slightly  to  relax  the  sphincter,  the  tube  is 
35 


546 


THE    COLON   AND   RECTUM 


inserted  into  the  anus,  guided  by  the  right  hand  in  which  it  is  held  at  a 
distance  of  about  2  inches  (5  cm.)  from  its  extremity,  the  operator 
using  a  slight  boring  motion,  and  bearing  in  mind  that  the  direction 
of  the  anal  canal  with  the  patient  recumbent  is  upward  and  slightly 
forward.  Having  traversed  the  anal  canal,  the  tube  enters  the  rec- 
tum proper,  and  is  then  slowly  advanced  in  an  upward  and  sHghtly 
backward  direction.  From  this  point  some  difi&culty  may  be  met 
with  in  passing  the  tube,  as  it  often  doubles  upon  itself  from  the 
point's  catching  in  a  fold  of  mucous  membrane  or  one  of  the  valves 
or  from  being  obstructed  by  feces.  Withdrawing  the  tube  slightly 
and  advancing  it  will  often  suffice  to  free  it;  in  other  cases  allowing  the 
fluid  to  flow  as  the  tube  is  advanced  displaces  or  removes  any  ob- 
struction and  at  the  same  time  causes  the  tube  to  straighten  out.  In 
this  manner  the  tube  may  be  passed  into  the  colon,  if  desired,  without 
causing  the  patient  any  great  discomfort,  provided  gentleness  and  no 
force  be  employed. 

When  the  tube  is  introduced  to  the  desired  height,  the  reservoir  is 
elevated  a  distance  of  2  or  3  feet  (60  to  90  cm.),  and  its  contents  are 
allowed  to  enter  the  bowel  slowly  (Fig.  566).     The  patient  is  apt  to 


Fig.  566. — Method  of  giving  a  low  enema.     (Macfarlane.) 


complain  of  fulness  in  the  rectum  as  the  fluid  enters  and  distends  it, 
but,  by  temporarily  stopping  the  flow,  this  feeling  soon  passes  off,  and, 
as  the  rectum  becomes  tolerant  to  the  pressure,  more  fluid  can  be 
injected.  When  the  desired  amount  has  been  introduced,  the  flow  is 
shut  off  by  pinching  the  tube,  which  is  then  withdrawn.  The  patient 
is  directed  to  hold  the  enema  as  long  as  possible  before  using  the 
bed-pan,  certainly  for  five  or  ten  minutes  at  least. 

Enteroclysis. — ^Like  enemata,  irrigations  are  used  mainly  for 
cleansing  purposes,  to  remove  putrefying  material  or  toxins  from  the 


ENEMATA   AND   ENTEROCLYSIS  547 

bowels,  and  to  bring  medicated  fluids  into  contact  with  diseased  areas 
of  mucous  membrane.  Large  irrigations  are  not  advised,  however,  in 
the  treatment  of  habitual  constipation;  the  use  of  small  enemata  is 
just  as  efficacious,  and  there  is  less  danger  of  producing  atony  of  the 
bowel  than  where  it  is  continually  overloaded  and  distended  with, 
large  quantities  of  fluid.  In  the  treatment  of  intestinal  toxemia  by 
enteroclysis,  the  bowels  are  thoroughly  cleansed  and  absorption  of  the 
toxins  from  the  decomposing  contents  is  prevented.  At  the  same 
time,  more  or  less  fluid  is  absorbed;  the  activity  of  the  skin,  kidneys, 
and  liver  is  consequently  stimulated  and  general  absorption  and 
autointoxication  are  greatly  lessened.  For  the  same  reasons  entero-" 
clysis  has  a  wide  field  of  usefulness  in  the  treatment  of  renal  insuffi- 
ciency, uremia,  toxemia,  general  septic  conditions,  etc.,  producing 
marked  diuresis,  and  not  only  diluting  the  toxins  in  circulation,  but 
favoring  their  elimination. 

Enteroclysis  with  hot  normal  salt  solution,  through  the  stimu- 
lating effect  on  the  circulation  and  the  elevation  of  bodily  tempera- 
ture, produces  marked  and  beneficial  results  in  shock  due  to  whatever 
cause  (see  Saline  Rectal  Infusions,  page  554). 

In  proctitis  and  in  catarrhal,  dysenteric,  and  ulcerative  conditions 
of  the  large  bowel  irrigations  are  employed  for  cleansing  purposes, 
removing  foreign  substances,  mucus,  and  pus,  and  thus  rendering 
bacteria  less  active;  they  also  serve  as  a  means  of  bringing  medicinal 
agents  in  contact  with  the  diseased  surfaces.  For  the  local  effect  upon 
diseases  of  the  rectum  or  adjacent  organs  irrigations  are  used  either 
hot  or  cold;  for  example,  in  the  treatment  of  internal  hemorrhoids  or 
hemorrhage  from  ulcers  situated  in  the  rectum  or  lower  bowel.  Such 
irrigations  are  likewise  employed  in  genitourinary  and  gynecological 
practice  for  the  treatment  of  congestion  and  inflammation  located 
in  the  bladder,  prostate,  and  deep  urethra,  or  the  uterus  and  its 
appendages. 

Apparatus. — The  reservoir  for  the  solution  may  be  either  a  quart- 
glass  irrigating  jar  or  a  fountain  syringe,  attached  to  which  is  about 
6  feet  (180  cm.)  of  rubber  tubing  1/4  to  3/8  inch  (6  to  9  mm.)  in 
diameter.  Irrigating  tubes  come  in  two  styles:  a  single-flow  tube, 
in  which  the  fluid  enters  and  escapes  through  the  same  tube,  and  a 
double-current  tube,  in  which  the  inflow  enters  and  the  outflow 
escapes  through  different  compartments. 

In  irrigating  with  a  single  tube,  it  will  prove  most  satisfactory 
to  use  a  colon  tube  about  20  inches  (50  cm.)  long  and  3/8  to  1/2 
inch  (9  to  12  mm.)  in  diameter,  with  the  opening  at  the  end.     With 


548 


THE    COLON    AND    RECTUM 


this  form  of  tube  fluid  may  be  deposited  high  in  the  colon  or  low  in 
the  rectum  at  will.  For  infants,  a  catheter,  i6  to  i8  French,  may  be 
used.  The  irrigating  tube  is  connected  to  the  end  of  the  rubber  tub- 
ing of  the  irrigator  by  a  T-shaped  glass  tube,  to  the  long  arm  of 
which  is  attached  a  short  piece  of  rubber  tubing  closed  by  a  clip 
(Fig.  567).     The  solution  is  passed  into  the  bowel  with  this  clip 


Pig.  567. — Apparatus  for  enteroclysis. 

closed,  and  when  it  is  to  be  drawn  off  the  inflow  of  solution  is  tempo- 
rarily stopped  by  pinching  the  tubing  between  the  glass  connection 
and  the  irrigator,  the  clip  is  opened,  and  the  fluid  returns  through  the 
same  tube  and  escapes  through  the  long  arm  of  the  T-tube  into  a 
waste-pail  ready  for  that  purpose.  The  same  thing  may  be  very 
simply  accomplished  with  a  long  colon  tube  and  a  funnel  (see  Fig. 


Fig.  568. — Kemp's  return-flow  irrigator. 


564).  The  solution  is  forced  in  through  the  funnel,  and,  when 
sufficient  has  entered  the  bowel,  the  funnel  is  depressed  and  the  fluid 
allowed  to  escape. 

With  a  double-flow  tube  irrigations  may  be  carried  out  far  more 
conveniently,  especially  when  several  gallons  of  fluid  are  used  at  each 
irrigation.     A  very  efficient  double-flow  apparatus,   especially  for 


ENEMATA  AND   ENTEROCLYSIS  549 

high  irrigating,  may  be  improvised  by  passing  a  moderate-sized 
single-flow  tube  high  into  the  bowel,  alongside  of  which  is  inserted  a 
second  tube  of  larger  caliber  to  carry  off  the  return  flow.  There  are 
any  number  of  excellent  double-flow  irrigators  on  the  market,  of  which 
Bodenhamer's,  Kemp's  (Fig.  568),  or  Tuttle's  tubes  are  satisfactory 
models.  These  instruments  are  made  of  hard  rubber  so  that  they 
may  be  readily  sterilized.  Tuttle's  irrigator  (Fig.  569)  consists  of  a 
cylinder  enclosing  a  smaller  tube  which  opens  at  the  end  of  the  irri- 
gator. This  smaller  tube  conducts  the  fluid  into  the  bowel.  The 
outside  cylinder  has  numerous  openings  in  its  sides  to  carry  off  the 
outflow.  It  ends  in  a  discharge  tube  to  which  a  long  piece  of  rubber 
is  attached  to  carry  off  the  waste. 

A  bath-thermometer,  a  douche-pan  or  a  bed-pan,  a  slop-pail,  and 
rubber  sheeting  to  protect  the  bed  complete  the  necessary  equipment. 

Solutions  for  Irrigation. — In  the  great  majority  of  cases,  unless  a 
specific  action  is  required  from  direct  contact  of  remedies  with  the 


^^^^^^^^^^^^ 


Fig.   569. — ^Tuttle's  return-flow  irrigator. 

surface  of  the  intestine,  normal  salt  solution  (dr.  i  (4.  gm.)  of  salt  to 
a  pint  (500  c.c.)  of  warm  water)  is  used.  For  cleansing  purposes 
and  to  aid  in  the  expulsion  of  flatus,  5  to  15  lU  (0.3  to  i  c.c.)  of 
oleum  cinnamomi  or  oleum  menthas  piperitae  may  be  added  to  each 
pint  of  solution. 

The  following  solutions  will  be  found  useful  in  catarrhal  or 
ulcerative  conditions  of  the  lower  bowel,  according  to  whether  a 
soothing,  antiseptic,  stimulating,  or  astringent  action  is  desired: 
aqueous  extract  of  krameria,  i  to  20;  fluid  extract  of  hydrastis,  i  to 
50;  fluid  extract  of  hamamelis,  i  to  50;  boric  acid,  i  to  20;  hydrogen 
peroxid,  i  to  10;  thymol,  i  to  50;  carbolic  acid,  i  to  500;  bichlorid 
of  m.ercury,  i  to  10,000;  permanganate  of  potash,  i  to  500;  saHcylic 
acid,  I  to  500;  quinin,  i  to  1000;  argyrol,  i  to  1000;  tannic  acid,  i  to 
500;  silver  nitrate,  i  to  2000,  etc.  In  using  the  more  powerful  and 
poisonous  drugs,  such  as  carbolic  acid  and  bichlorid  of  mercury,  for 
instance,  any  excess  of  solution  remaining  in  the  bowel  at  the 
completion  of  the  irrigation  should  be  drained  off  before  withdrawing 
the  tube. 


55 O  THE    COLON   AND   RECTUM 

Temperature. — This  will  depend  upon  the  condition  for  which  the 
irrigation  is  employed  and  upon  the  action  desired.  For  simple 
cleansing  purposes  and  in  the  treatment  of  colitis  and  dysentery  the 
irrigation  should  enter  the  bowel  at  a  temperature  of  ioo°  to  105°  F. 
(38  to  41°  C.)-  Hot  irrigations  (110°  to  115°  F.  (43°  to  46°  C.))  are 
indicated  when  the  stimulating  action  of  heat  is  desired,  or  for  the 
diuretic  effect  and  to  increase  the  eliminative  action  of  the  skin,  and 
for  the  effect  of  heat  upon  inflammations  of  neighboring  organs. 

Cold  enteroclysis  (65°  to  70°  F.  (18°  to  21°  C.))  has  a  beneficial 
action  upon  the  whole  intestinal  tract,  toning  up  the  mucous  mem- 
brane and  stimulating  the  muscular  tissue,  and  so  increasing  peri- 
stalsis. This  is  indicated  in  the  treatment  of  internal  hemorrhoids, 
inflammatory  conditions  of  the  rectum,  prostate,  deep  urethra,  etc. 
Li  hemorrhage  from  the  bowel,  very  cold  (50°  F.  fio°  C.))  or  very 
hot  (120°  F.  (49°  C.))  irrigations  are  used.  It  should  not  be  for- 
gotten, however,  that  prolonged  enteroclysis  with  very  hot  or  very 
cold  fluid  will  cause  a  rise  or  lowering  of  the  bodily  temperature 
amounting  to  several  degrees. 

Rapidity  of  Flow. — The  fluid  should  enter  the  bowel  with  com- 
parative slowness,  to  avoid  exciting  peristalsis  and  to  allow  the  fluid 
to  be  well  distributed  over  the  intestinal  wall.  Elevation  of  the 
reservoir  2  to  3  feet  f6o  to  90  cm.)  for  a  low  irrigation  and  3  to  4  feet 
(90  to  120  cm.)  for  the  high  will  give  the  proper  flow. 

Quantity. — A  continuous  irrigation  of  from  ten  minutes  to  one- 
half  an  hour  or  more  at  a  time  gives  the  best  results  in  septic 
conditions,  toxemias,  inflammations  in  the  organs  adjacent  to  the 
bowel,  etc.  Several  gallons  of  solution  are  needed  for  such  an  irri- 
gation. On  an  average,  from  i  to  i  1/2  pints  (5CXD  c.c.  to  750  c.c.)  of 
solution  in  high  enteroclysis,  and  from  2  to  8  ounces  (60  to  240  c.c.) 
in  the  low  irrigation  are  kept  in  the  bowel  continuously.  For 
cleansing  purposes,  and  in  the  treatment  of  diseases  involving  the 
mucous  membrane  of  the  bowel,  the  irrigation  is  continued  until  the 
solution  returns  clear. 

Position  of  the  Patient. — Enteroclysis  may  be  performed  with  the 
patient  (ij  in  the  dorsal  position,  with  hips  elevated;  {2)  in  the  Sims, 
or  left  lateral  prone  position;  and  (3)  in  the  knee-chest  posture. 

\\Tien  it  is  desired  to  irrigate  the  whole  colon  thoroughly,  the 
position  of  the  patient  may  be  altered  to  advantage  from  time  to 
time  in  order  to  allow  the  force  of  gravity  to  act  upon  the  fluid  and 
permit  it  to  reach  all  portions  of  the  colon.  Elevation  of  the  patient's 
hips  causes  the  fluid  to  gravitate  toward  the  transverse  colon,  and 


ENEMATA   AND    ENTEROCLYSIS 


551 


thence  along  this  portion  of  the  bowel  to  the  ascending  colon  if  the 
patient  is  shifted  from  the  left  side  to  the  right. 

Technic. — The  apparatus  is  properly  connected  and  the  reservoir 
is  filled  with  the  solution,  first  allowing  a  little  to  escape  from  the 
nozzle  to  expel  any  air  and  to  see  that  everything  works  properly. 
Practically  the  same  steps  are  followed  in  inserting  the  tube  for 
enteroclysis  as  were  detailed  for  giving  an  enema.  The  tube,  well 
lubricated  with  vaselin  or  oil,  is  grasped  in  the  fingers  of  the  right 
hand  not  far  from  its  extremity,  while  the  left  hand  separates  the 


Fig.  570. — Showing  one  method  of  irrigating  the  bowels  with  a  single  tube. 

patient's  buttocks.  The  patient  is  instructed  to  strain  sufficiently  to 
relax  the  sphincter,  and  the  tube  is  inserted  at  first  upward  and 
forward  for  a  distance  of  2  to  3  inches  (5  to  7.5  cm.)  and  then  upward 
and  sHghtly  backward  toward  the  sacrum.  There  is  very  little 
difficulty  in  passing  a  rectal  tube  or  an  irrigating  nozzle  the  necessary 
distance  for  a  low  irrigation,  if  the  normal  direction  of  the  bowel  is 
followed,  a  well-oiled  tube  almost  slipping  in  of  its  own  accord  at 
times.  To  pass  a  flexible  tube  the  remainder  of  the  way  into  the 
sigmoid  is  not  so  simple,  as  it  is  not  possible  to  guide  the  tube  after 


552 


THE    COLON    AND    RECTUM 


it  gets  3  or  4  inches  (7.5  or  10  cm.)  into  the  bowel,  and  it  has  to  prac- 
tically find  its  own  way  along.  It  will  be  found  a  distinct  aid,  how- 
ever, in  accomplishing  this  if  the  solution  is  allowed  to  flow  gently  as 
soon  as  the  anal  canal  is  passed.  This  tends  to  make  the  tube 
stiffer  and  at  the  same  time  it  straightens  out  the  folds  of  mucous 
membrane  and  carries  the  valves  out  of  the  way,  which  might  other- 


FlG.  571. — Showing  the  method  of  irrigating  the  bowels   by  means  of  a  funnel 

and  colon  tube. 


wise  form  obstructions.  When  the  tube  has  been  inserted  to  the 
desired  distance,  the  reservoir  is  raised  3  or  4  feet  (90  or  120  cm.), 
and  the  washing-out  process  begins. 

In  performing  enteroclysis  with  a  single  tube,  i  or  i  1/2  quarts 
(i  to  1.5  liters)  of  solution — depending  upon  the  capacity  and  toler- 
ance of  the  individual — are  allowed  to  flow  into  the  bowel  before  the 
fluid  is  permitted  to  return.  If  the  fluid  enters  the  bowel  slowly  and 
the  desire  on  the  part  of  the  patient  to  expel  it  be  resisted  a  few 
moments  until  it  passes  well  into  the  colon,  no  great  difiiculty  will  be 
encountered.     To  withdraw  the  fluid,  the  outlet  placed  in  the  tube 


EXEilATA    AXD    EXTEROCLYSIS 


OOO 


leading  from  the  reservoir  is  opened  (Fig.  570),  or,  if  a  funnel  con- 
stitutes the  reservoir,  this  is  simply  lowered  below  the  level  of  the 
patient,  and  the  solution  escapes  through  the  same  tube  by  which 
it  entered  (Fig.  571).  This  process  of  lavage  is  repeated  until  the 
fluid  returns  clear. 

The  colon  may  be  more  thoroughly  irrigated,  as  already  men- 
tioned, by  altering  the  patient's  position  as  follows :     With  the  patient 


Fig.  572. — Showing  the  method  of  irrigating  the  bowel  by  means  of  a  return-flow 

irrigator. 

in  the  Sims  position,  for  instance,  and  with  the  hips  elevated,  the 
descending  colon  is  first  thoroughly  washed  out.  About  i  1/2  to  2 
pints  (750  to  1000  c.c.)  of  solution  are  then  retained,  and  the  patient 
is  gradually  rolled  to  the  dorsal  position  and  then  to  the  right  side. 
This  permits  the  fluid  to  pass  from  the  descending  colon  to  the  trans- 
verse and  ascending  colon.  To  allow  the  solution  to  gravitate  down 
the  ascending  colon  to  the  caput  coli,  the  patient's  shoulders  are 
raised  slightly  higher  than  his  hips.  The  process  is  then  exactly 
reversed :  the  shoulders  are  first  lowered,  the  patient  then  rolls  to  the 
dorsal  position,  and  finally  to  the  left  side  again. 


554 


THE    COLON   AND   RECTUM 


In  using  the  double-flow  style  of  irrigator,  the  outflow  tube  is 
compressed  until  a  pint  (500  c.c.)  or  more  of  solution  runs  into  the 
bowel  (Fig.  572),  when  it  is  released,  the  solution  still  continuing  to 
flow  in.  In  this  way  a  current  is  soon  established,  and  the  descending 
colon  and  rectum  are  thoroughly  washed  out.  During  the  irrigation 
the  reservoir  should  not  be  allowed  to  become  empty,  the  supply  being 
replenished  as  often  as  necessary.  In  withdrawing  an  irrigator  or  a 
tube  with  openings  upon  the  side,  care  should  be  taken  to  rotate  the 
instrument  slightly  to  prevent  the  mucous  membrane  from  being 
caught  in  the  fenestrae. 

SALINE  RECTAL  INFUSIONS 

The  value  of  saline  infusions  in  the  treatment  of  hemorrhage  and 
in  the  prevention  and  relief  of  surgical  shock  has  already  been  con- 
sidered in  Chapter  V.  The  rectal  infusion,  being  a  somewhat  slower 
and  less  effective  method  of  introducing  salt  solution  into  the  circu- 
lation than  either  the  intravenous  or  the  subcutaneous  methods,  is 
used  with  greater  success  in  the  milder  forms  of  shock  and  hemor- 
rhage, and  in  the  severe  cases  as  an  adjunct  to  intravenous  infusion 
or  hypodermoclysis.  It  has,  however,  the  distinct  advantage  of 
simplicity  over  the  other  two  methods,  requiring  no  preparation  of 
the  patient  and  but  the  crudest  form  of  apparatus;  hence  its  value 
as  an  emergency  measure.  In  septic  conditions,  toxemias,  renal 
insufficiency,  uremia,  etc.,  the  fluid  thus  introduced  into  the  bowel 
is  rapidly  absorbed,  and  the  skin,  kidneys,  and  liver  are  stimulated 
to  increased  activity,  with  the  rapid  elimination  of  poisonous 
products  as  a  result.  Rectal  infusions  are  also  indicated  when  it 
is  desirable  to  increase  the  quantity  of  fluid  in  the  tissues,  as,  for 
example,  in  cases  where  large  quantities  of  fluid  are  lost  from  purg- 
ing, as  in  dysentery  or  cholera.  It  is,  furthermore,  a  most  valuable 
means  of  relieving  the  thirst  so  frequently  complained  of  after 
abdominal  operations. 

Apparatus. — The  equipment  will  not  differ  from  that  used  in 
giving  an  ordinary  enema.  There  will  be  required  a  thermometer, 
a  graduated  glass  irrigating  jar  or  fountain  syringe,  6  feet  (180  cm.) 
of  rubber  tubing,  about  1/4  to  3/8  inch  (6  to  9  mm.)  in  diameter, 
and  a  rectal  tube,  20  inches  (50  cm.)  long  and  3/8  to  1/2  inch  (9  to 
12  mm.)  in  diameter.  In  an  emergency,  a  large  funnel  will  answer 
as  a  reservoir,  and  a  large  long  soft-rubber  catheter  will  take  the 
place  of  the  rectal  tube. 


SALIXE    RECTAL   INFUSION  555 

Solution. — Normal  salt  solution,  (dr.  i  (4.  gm.)  of  salt  to  a  pint 
(500  c.c.)  of  water)  is  used.  For  a  stimulating  effect,  whisky  or 
brandy,  oz.  ss.  to  oz.  i  (15  to  30  c.c.)  may  be  added.  In  surgical 
shock  30  TTL  (2  c.c.)  of  a  I  to  1000  solution  of  adrenalin  chlorid  may 
be  added  to  the  enema  for  the  purpose  of  raising  blood-pressure. 

Temperature.— The  solution  should  enter  the  bowel  at  a  tem- 
perature of  110°  to  115°  F.  (43°  to  46°  C).  As  there  is  but  httle 
loss  of  heat  on  account  of  the  rapidity  of  the  flow,  the  solution  in  the 
reservoir  should  be  at  the  same  temperature  at  which  it  is  desired 
to  have  it  enter  the  bowel,  or  not  more  than  one  or  two  degrees 
higher. 

Rapidity  of  Flow. — The  fluid  should  be  introduced  slowly  and  not 
with  such  rapidity  as  to  excite  intestinal  spasm.  With  this  in  view, 
the  reservoir  is  held  not  over  3  to  4  feet  (90  to  120  cm.)  above  the 
patient. 

Quantity. — Small  amounts  are  more  apt  to  be  retained  by  the 
bowel.  From  1/2  pint  (250  c.c.)  to  a  quart  (1000  c.c.)  may  be  given 
at  a  single  injection. 

Position  of  the  Patient. — The  infusion  may  be  given  with  the 
patient  preferably  in  the  Sims  position  with  the  hips  raised  or  else 
in  the  knee-chest  position.  If  it  is  not  expedient  to  move  the 
patient  about,  the  dorsal  position  with  the  hips  elevated  and  with 
the  knees  drawn  up  may  be  substituted. 

Technic. — The  reservoir  is  filled  with  the  required  amount  of 
solution  of  the  proper  temperature,  and  a  thermometer  is  placed 
in  it  that  the  temperature  may  be  kept  uniform.  The  rectal  tube 
should  be  well  lubricated  with  vaselin  or  oil.  Some  of  the  solution 
is  then  allowed  to  escape  from  the  tube  to  expel  any  air  or  cold 
fluid.  The  flow  is  then  shut  ofl'  and  the  tube  is  grasped  in  the  fingers 
of  the  right  hand  about  2  inches  (5  cm.)  from  its  extremity  while 
the  left  hand  separates  the  buttocks.  As  the  patient  strains  slightly, 
relaxing  the  sphincter,  the  tube  is  gently  inserted  into  the  rectum. 
In  doing  this  the  normal  direction  of  the  bowel  with  the  patient  in 
the  dorsal  posture — first  upward  and  forward,  and  then  upward 
and  backward — must  be  kept  in  the  mind  of  the  operator.  When 
the  internal  sphincter  is  passed,  the  solution  is  again  aUowed  to 
flow  gently,  in  order  to  displace  any  feces,  folds  of  mucous  membrane, 
etc.,  that  might  act  as  an  obstruction,  and  the  tube  is  pushed  on  into 
the  bowel  for  a  distance  of  at  least  8  to  10  inches  (20  to  25  cm.). 
The  reservoir  is  then  raised  from  3  to  4  feet  (90  to  120  cm.),  and  the 
required  amount  of  solution  is  introduced.     If  it  is  injected  slowly 


556 


THE    COLON    AND    RECTUM 


and  the  tube  is  passed  high  up,  no  difficulty  will  be  found  in  intro- 
ducing and  having  retained  often  as  much  as  a  quart  (looo  c.c.)  of 
solution.  At  the  completion  of  the  operation  the  tube  is  withdrawn 
and  the  patient  is  instructed  to  remain  quiet  in  the  recumbent 
position. 

CONTINUOUS  PROCTOCLYSIS 

By  this  method  a  continuous  stream  of  saline  solution  is  instilled 
into  the  rectum  at  very  low  pressure.  Given  slowly,  so  as  not  to 
irritate  the  rectum,  enormous  quantities  of  salt  solution  may  be  thus 
absorbed.     It  was  originally  employed  by  Murphy  in  the  treatment 


Fig.  573. — A  very  simple  apparatus  for  continuous  proctoclysis. 

of  septic  peritonitis  in  conjunction  with  free  abdominal  drainage, 
on  the  theory  that  the  large  quantity  of  fluid  absorbed  reverses  the 
lymph  currents,  so  that,  instead  of  absorption  taking  place  from  the 
peritoneal  surface,  the  lymphatics  pour  out  fluid  and  wash  out  the 
peritoneum,  as  it  were.  At  the  same  time,  stimulation  of  the  heart 
and  kidneys  results,  and  with  the  latter  an  increased  elimination  of 
toxins  and  septic  material.  While  employed  mainly  in  cases  of 
peritonitis,  where  the  results  have  certainly  been  marvelous,  con- 
tinuous proctoclysis  will  be  found  an  excellent  means  of  infusing 


CONTINUOUS   PROCTOCLYSIS 


557 


salt  solution  in  any  septic  condition  or  general  toxemia,  shock, 
uremia,  etc. 

Apparatus. — A  glass  reservoir  or  a  fountain  syringe  with  a 
capacity  of  at  least  2  quarts  (2  liters),  3  to  4  feet  (90  to  120  cm.)  of 
rubber  tubing  1/4  to  3/8  of  an  inch  (6  to  9  mm.)  in  diameter,  and  a 
vaginal  nozzle  of  hard  rubber  with  numerous  openings  on  the  sides, 
bent  at  an  angle  of  35  degrees  about  2  inches  (5  cm.)  from  the  tip 
(Fig.  573)  forms  the  simplest  apparatus.  A  soft-rubber  catheter 
may  be  used  in  place  of  the  hard  nozzle,  if 
desired.  Hot-water  bags  or  hot-water  cans,  which 
surround  the  reservoir  and  prevent  the  solution 
from  cooling,  should  also  be  provided.  An  indi- 
cator, placed  in  the  outflow  tube  to  show  the  rate 
of  flow,  is  a  great  convenience.  A  simple  one  is 
described  by  Dewitt  {Surgery,  Gynecology  and 
Obstetrics,  February,  191 1).  The  plunger  is 
removed  from  a  6-inch  (15  cm.)  metal- topped 
glass  syringe  and  the  metal  top  is  perforated  wilh 
from  2  to  4  holes  for  the  escape  of  gas,  and  through 
the  opening  for  the  plunger  is  inserted  a  glass 
medicine  dropper.  The  upper  end  of  the  dropper  is 
connected  with  the  reservoir  by  a  short  piece  of 
rubber  tubing  carrying  a  screw  clamp  (Fig.  574), 
while  the  tip  of  the  syringe  is  attached  to  the  rectal 
tubing.  By  means  of  this  simple  device  the  rate  of 
flow  may  be  observed  and  an  outlet  is  provided  for 
flatus. 

Saxon  has  devised  an  apparatus  especially  for 
proctoclysis  (Fig. 5 75),  consisting  of  a  copper  bucket, 
inside  of  which  is  placed  a  glass  reservoir  for  the  Fig.  574. — Mod- 
salt  solution.  Between  the  copper  bucket  and  ification  of  De- 
reservoir  is  provided  a  space   of    2    1/2   inches    (6    T"'^  appliance 

,  A      1  ^°^  regulating  the 

cm.)  for  hot  water.  A  thermometer  is  placed  in  Aq^  of  solution 
the  tubing  which  leads  from  the  reservoir,  and  a  vent  in  proctoclysis. 
pipe  for  the  escape  of  flatus  is  also  provided.  (Crandon      and 

.  .        1  .         1  .1      ,      1  Ehrenfried.) 

A  very  simple  apparatus  is  described  by 
Iversen  {Jour.  Am.  Med.  Assoc,  June  12,  1909)  in  which  the 
solution  is  kept  at  the  required  temperature  by  means  of  an 
8-candle-power  electric  lamp.  The  mechanism  is  sufficiently 
clear  from  the  accompanying  illustration  (Fig.  576).  There  are 
a   number  of  more  elaborate  forms  of  apparatus    made,  however, 


558 


THE    COLON   AND   RECTUM 


in    which    the    heat    is    furnished  by  a  thermolite  warmer  or    by- 
electricity. 

Solution. — Normal  salt  solution  (dr.  i  (4  gm.)  of  salt  to  a  pint 
(500  c.c.)  of  water),  or  plain  boiled  tap  water  may  be  used.  The 
latter  has  been  employed  to  a  great  extent  in  the  last  few  years, 
as  it  has  been  found  that  the  large  bowel  tolerates  warm  water  as 
well  as  it  does  saline  solutions;  furthermore,  thirst  is  more  quickly 
and  effectively  relieved. 


Fig.  575.  Fig.  576. 

Fig.  575. — Saxon's  apparatus  for  continuous  proctoclysis. 

Fig.  576. — Iversen's  apparatus  for  continuous  proctoclysis,  a.  Eight-candle- 
power  electric  bulb;  b,  cock;  c,  Y-shaped  glass  connection-  d,  vent  tube  for  the 
escape  of  gas. 


Temperature. — The  solution  should  be  at  a  temperature  of  about 
100°  to  105°  F.  (38°  to  41°  C.)  as  it  enters  the  rectum,  and  it  must 
therefore  be  at  a  temperature  of  from  120°  to  130°  F.  (49°  to  54°  C.) 
in  the  reservoir.  The  solution  must  be  kept  at  a  uniform  degree 
of  heat  by  either  constantly  replenishing  with  hot  solution  or  by 
surrounding  the  reservoir  with  hot-water  bags,  unless  one  of  the 
special  heating  devices  is  employed. 

Rapidity  of  Flow. — The  salt  solution  just  trickles  into  the  bowel, 
not  much  faster  than  it  is  absorbed,  at  about  the  rate  of  60  to  180 
drops  a  minute.     In  this  way  i  to  3  pints  (500  to  1500  c.c.)  will 


CONTINUOUS   PROCTOCLYSIS 


559 


flow  into  the  rectum  in  about  an  hour.  The  reservoir  should  be 
elevated  only  from  4  to  i8  inches  (10  to  45  cm.)  above  the  level  of 
the  rectum,  depending  upon  the  rate  of  absorption,  and  the  elevation 
of  the  reservoir  must  be  so  regulated  that  no  accumulation  of  fluid 
occurs  in  the  bowel. 

Quantity. — The  instillation  is  practically  continuous,  and  the 
quantity  of  fluid  introduced  is  limited  only  by  the  absorbing  power 
of  the  rectum.  From  6  to  15  quarts  (6  to  15  liters)  may  be  absorbed 
in  twenty-four  hours.     ]Murphy  has  given   as  much  as  30  pints 


Fig.  577. — Showing  the  method  of  administering  continuous  proctoclysis. 
(Kelly  and  Noble.)  a.  Adhesive  strap  fastening  the  tubing  to  the  thigh;  b,  vaginal 
nozzle  bent  at  an  angle  of  35  degrees. 

(15  liters)  in  twenty-four  hours  to  a  child  of  eleven.  It  was  all  re- 
tained. Monroe,  however,  sounds  a  note  of  warning  against  over- 
use of  this  method,  claiming  that  it  is  possible  for  a  patient  to  absorb 
more  fluid  than  can  be  eliminated,  shown  by  an  overfull  pulse,  by 
cough,  and  by  rales  from  edema  of  the  lungs. 

Technic. — The  reservoir  is  filled  with  solution  and  suflicient 
fluid  is  allowed  to  escape  to  expel  any  air  from  the  tubing.  The 
right-angled  nozzle,  well-lubricated,  is  introduced  into  the  rectum 
just  beyond  the  sphincter  muscle,  so  that  the  angle  fits  closely  to 
the  anus,  and  is  secured  in  place  by  adhesive  plaster  passing  to  the 
thigh  (Fig.  577).  The  reservoir  is  then  raised  about  6  inches  (15 
cm.) — just  sufiiciently  high  to  overcome  the  intraabdominal  pressure 
and  allow  the  fluid  to  trickle  into  the  bowel.     Forceps  or  other  means 


:6o 


THE    COLON   AND   RECTUM 


of  constriction  should  not  he  applied  to  the  tube  to  regulate  the  flow, 
unless  the  apparatus  be  provided  with  an  accessory  vent  to  carry 
off  the  flatus,  as  they  interfere  with  the  free  expulsion  of  gas  through 
the  tube  or  the  return  of  fluid  to  the  reservoir  should  the  patient 
strain  or  vomit.  The  injection  may  be  stopped  every  few  hours 
if  the  pulse  becomes  too  full  or  the  rectum  irritable;  in  such  cases 
the  tube  is  not  disturbed.  Murphy  advises  that  the  tube  should 
not  be  removed  except  for  defecation,  as  the  constant  reinsertion 
will  prove  irritating  to  the  rectum.  It  is  rarely  necessary  to  con- 
tinue the  proctoclysis  for  more  than  three  or  four  days.  Exact 
technic  and  almost  constant  attention  on  the  part  of  the  nurse  are 
necessary  to  gain  success  with  this  method. 


NUTRIENT  ENEMATA 

The  nutrient  enema  is  employed  in  cases  when  feeding  by  the 
natural  way  is  undesirable  or  impracticable.  Rectal  feeding  has  its 
time  limitations,  however.  The  capacity  of 
the  rectum  is  small  and  absorption  is  con- 
siderably slower  than  by  the  natural  way,  so 
that  only  about  a  quarter  of  the  amount  of 
nourishment  necessary  for  sustenance  can  be 
given  in  this  way.  As  a  temporary  expedient 
or  as  an  adjunct  to  natural  feeding  it  is  most 
useful,  but  for  permanent  feeding  it  is  quite 
impracticable.  If  it  alone  is  depended  upon 
for  nourishment,  life  can  rarely  be  prolonged 
for  more  than  four  to  six  weeks,  though  it 
is  true  that  certain  exceptional  cases  have 
been  reported  where  patients  have  lived 
exclusively  upon  rectal  feeding  for  longer 
periods. 

Indications. — i.  In  cases  where  some    im- 
pediment to    the    passage  of   food   exists,    as 
esophageal   stricture,    new  growths   encroach- 
FiG.    578.— Funnel    ^^S  upon    the    esophagus,  and    in    pyloric    or 
and    colon    tube    for    duodenal     stenosis.      2.     In      incessant     and 
administering  nutrient    uncontrollable  vomiting.     3.  In  any  condition 
enema  a.  where  it  is  desirable   to   give  the   alimentary 

tract  a  rest,  as  in  acute  inflammation  or  ulceration  of  the  upper 
part  of  the  alimentary  canal,  acute  gastritis,  gastric  ulcer,  typhoid 
fever,  and   lesions   of   the   small  intestine.     4.  As    an    adjunct   to 


CONTINUOUS    PROCTOCLYSIS 


561 


natural  feeding  in  any  condition  when  the  patient  cannot  receive 
sufficient  nourishment  by  mouth. 

Apparatus. — A  large  glass  funnel,  2  to  3  feet  (60  to  90  cm.)  of 
rubber  tubing  1/4  to  2>/^  of  an  inch  (6  to  9  mm.)  in  diamicter,  and  a 
plain  rectal  tube  20  inches  (50  cm.)  long,  No.  35  French  in  size  (Fig. 
578)  make  a  simple  and  very  effective  apparatus,  and  one  that  can 
be  easily  cleaned.  If  desired,  a  hard-rubber  syringe  with  a  capacity 
of  from  4  to  6  ounces  (120  to  180  c.c.)  (Fig.  579)  or  a  Davidson 
syringe  attached  directly  to  the  rectal  tube  may  be  used.  In  children 
a  No.  18  to  20  French  ordinary  rubber  catheter  is  substituted  for 
the  rectal  tube. 


Fig.  579. — Colon  tube  and  syringe  for  administering  nutrient  enemata.      (Ashton.) 


Asepsis. — The  tube  should  be  boiled  before  using,  and  it  must  be 
carefully  cleaned  after  each  injection.  Syringes,  if  employed,  should 
likewise  be  very  thoroughly  cleansed  with  soap  and  water  every  time 
they  are  used. 

Material  Employed  for  Feeding. — Whatever  the  form  of  nourish- 
ment used,  it  must  be  free  from  all  irritating  properties  and  should 
be  small  in  bulk,  or  it  will  be  immediately  expelled.  As  the  lower 
bowel  secretes  no  digestive  ferments,  the  substances  injected  must  be 
of  such  a  nature  that  they  are  readily  absorbed,  otherwise  the  enema 
acts  as  a  foreign  body  and  proves  irritating  to  the  bowel.  The 
food,  should  always  be  fluid  in  character  and.  as  far  as  is  possible, 
predigested.  As  a  general  thing,  starches  and  fats  are  to  be  avoided. 
Combinations  of  pancreatinized  meat  extracts,  peptonized  milk,  and 
36 


562  THE  COLON  AND  RECTUM 

egg  albumen  will  be  found  to  be  most  readily  taken  up  by  the  bowel. 
The  addition  of  a  small  quantity  of  salt  to  each  egg  aids  in  its  absorp- 
tion. Alcohol  in  the  form  of  red  wine,  brandy,  or  whisky  may  be 
incorporated  in  the  enema  when  a  stimulating  effect  is  desired.  A 
good  stimulating  enema  consists  of  brandy  oz.  ii  (60  c.c),  ammonium 
carbonate  gr.  xx  (1.3  gm.),  and  beef  tea  q.s.  ad  oz.  viii  (240  c.c.)-  A 
pint  (500  c.c.)  of  black  coffee  alone  has  also  a  marked  stimulating 
effect. 

The  following  formulae  (Ashton)  will  be  found  very  useful.  In 
continued  rectal  feeding  it  is  well  to  use  them  in  rotation. 

(i)  Beef  juice  oz.  iii  (90  c.c),  and  liquor  pancreatis  dr.  ii  (8  c.c). 

(2)  One  raw  egg;  salt,  gr.  xv  (i  gm.);  brandy  or  whisky  oz.  ss. 
(15  c.c);  and  peptonized  milk  oz.  iii  (90  c.c). 

(3)  One  egg;  liquor  pancreatis  dr.  ii  (8  c.c);  and  beef  juice  oz. 
iii  (90  c.c). 

(4)  One  raw  egg,  and  peptonized  milk  oz.  iii  (90  c.c). 

(5)  Salt,  gr.  XV  (i  gm.);  beef  juice  oz.  i  (30  c.c);  and  peptonized 
milk  oz.  iii  (90  c.c). 

(6)  Yolk  of  one  raw  egg;  brandy  or  whisky  dr.  vi  (24  c.c); 
liquor  pancreatis  dr.  ii  (8  c.c);  and  beef-tea  oz.  iii  (90  c.c). 

Temperature. — Give  the  injection  at  a  temperature  near  that  of 
the  body,  about  95°  F.  (35°  C). — never  cold  or  very  hot — as  peris- 
talsis may  be  excited  and  the  rectum  will  probably  reject  the  feeding. 

Quantity. — Only  a  small  amount  of  food  should  be  injected  at  one 
time,  usually  i  to  6  ounces  (30  to  180  c.c),  depending  on  the  retain- 
ing capacity  of  the  rectum  and  whether  the  patient  is  a  child  or  an 
adult.    Large  quantities  are  liable  to  be  expelled  by  the  bowel. 

Frequency  of  Feedings.— This  will  depend  upon  the  quantity  taken 
at  one  time,  A  patient  who  can  retain  as  much  as  6  ounces  (180  cc) 
need  only  be  fed  every  six  hours.  Cases  where  but  small  amounts  are 
retained  will  require  three-  to  four-hour  interval  feedings. 

Care  of  the  Rectum. — A  cleansing  enema,  consisting  of  salt  dr. 
ii  (8  gm.)  to  a  quart  (1000  c.c.)  of  lukewarm  water,  is  given  each 
morning  at  least  an  hour  before  the  first  feeding.  This  serves  to 
wash  out  of  the  bowel  any  particles  of  waste  matter  or  mucus;  it 
furthermore  cleanses  the  mucous  membrane  and  prepares  it  for  more 
thorough  absorption  by  stimulating  the  circulation. 

Position  of  the  Patient. — In  giving  any  retained  enema  the  patient 
should  preferably  be  in  the  Sims  position  with  the  hips  elevated  or  in 
the  knee-chest  position.  If  it  is  inexpedient  to  move  the  patient,  the 
dorsal  position  with  hips  elevated  and  knees  drawn  up  will  sufl&ce. 


I^7ECTI0X5    OF    rLUID    OR    AIR    INTO    THE   BOWEL  563 

Technic. — The  tube  is  well  lubricated  with  sterile  vaselin  or  with 
sweet  oil  to  facilitate  its  passage  and  to  avoid  irritating  the  rectum. 
The  tube  is  slowly  and  gently  introduced,  according  to  the  direc- 
tions already  given  for  the  introduction  of  the  enema  or  enteroclysis 
tube  (see  page  545;,  well  into  the  bowel  for  a  distance  of  10  to  12 
inches  (25  to  30  cm.),  so  as  to  prevent  expulsion  of  the  food  and  fur- 
nish an  extensive  surface  for  absorption.  To  avoid  injecting  air, 
the  tube  and  the  reservoir  or  the  syringe  are  filled  with  the  material 
to  be  injected  before  the  tube  is  inserted  into  the  rectum.  The  fluid 
must  be  injected  very  slowly.  When  the  proper  amount  is  intro- 
duced, the  tube  is  carefully  removed  and  the  patient  is  instructed  to 
remain  quietly  in  the  recumbent  position  ^^dth  the  hips  elevated  for 
at  least  half  an  hour,  to  lessen  the  chances  of  the  food  being  expelled. 
In  cases  of  marked  irritability  of  the  rectum,  5  to  10  lU.  ^0.3  to  0.6 
c.c.)  of  the  tincture  of  opium  may  be  added  to  the  enema. 

INJECTIONS  OF  FLUID  OR  AIR  INTO  THE  BOWEL  IN 
INTUSSUSCEPTION 

The  slow  injection  of  bland  fluids  or  air  into  the  bowel  may  be 
employed  for  its  mechanical  effect  in  overcoming  an  obstruction  due 
to  intussusception.  Success  from  either  method,  however,  depends 
largely  upon  an  early  diagnosis  of  the  condition,  for  disinvagination 
becomes  more  difiicult  in  direct  proportion  to  the  length  of  time  which 
has  elapsed  from  the  onset  of  the  S}-mptoms.  After  the  first  t-wenty- 
four  hours  of  an  attack,  attempts  at  reduction  by  means  of  hydrostatic 
or  gaseous  pressure  are  not  justifiable,  as  tight  adhesions,  which  render 
reduction  impossible,  or  strangulation  and  partial  necrosis  of  the  gut 
■v^dth  the  added  danger  of  rupture  may  be  present.  The  greatest 
objection  to  this  method  of  treatment  lies  in  the  fact  that  in  many 
cases  it  is  impossible  to  tell  immediately  whether  the  invagination  has 
been  reduced,  and  the  success  of  the  procedure  can  only  be  determined 
by  allowing  the  patient  to  come  out  of  the  anesthetic  and  carefully 
observing  the  symptoms. 

Not  more  than  fifteen  minutes  to  a  half  hour  should  be  consumed 
in  attempts  at  rehef  by  these  nonoperative  measures.  In  all  cases 
preparations  for  operation  should  be  made  beforehand  so  that,  should 
reduction  fail,  an  immediate  laparotomy  can  be  performed.  Treat- 
ment by  injections  is,  of  course,  only  appHcable  when  the  intussus- 
ception occurs  in  the  large  bowel,  on  account  of  the  obstruction  by  the 
ileo-cecal  valve  to  the  passage  01  fluid  or  gas  into  the  small  intestine. 


564  THE    COLON    AND    RECTUM 

Treatment  by  Injection  of  Fluid. — Apparatus. — A  fountain 
syringe  or  a  graduated  glass  irrigating  jar  as  a  reservoir  and  a  rectal 
nozzle  or  a  large  catheter,  attached  to  the  reservoir  by  6  feet  (180  cm.) 
of  rubber  tubing  1/4  to  3/8  inch  (6  to  9  mm.)  in  diameter,  should  be 
provided. 

Solutions  Employed. — Normal  salt  solution — salt  dr.  i  (4  gm.) 
to  a  pint  (500  c.c.)  of  water — thin  gruel  or  milk  and  water  may 
be  used. 

Temperature. — As  the  relaxing  effect  of  heat  is  desirable,  the 
solution  should  be  at  a  temperature  of  about  105°  F.  (41°  C.)  as  it 
enters  the  bowel. 

Quantity. — The  capacity  of  the  colon  varies  from  10  ounces 
(300  c.c.)  in  a  child  of  five  months  to  a  pint  (500  c.c.)  or  more  in  a 
child  a  year  old.  Not  more  than  i  1/2  pints  (750  c.c.)  of  solution 
should  be  injected  into  the  bowel  of  a  child  under  one  year.  In  an 
adult,  the  rectum  and  colon  hold  as  much  as  9  pints  (4.5  liters)  with- 
out undue  distention. 

Rate  of  Flow. — The  fluid  should  enter  the  bowel  in  a  gradual, 
steady,  continuous  flow.  From  ten  to  fifteen  minutes  are  consumed 
in  injecting  the  given  quantity  of  solution. 

Amount  of  Pressure. — Starting  with  the  reservoir  elevated  about 
3  feet  (90  cm.),  which  gives  a  pressure  of  less  than  2  pounds,  the 
height  may  be  slowly  increased  to  4  or  5  feet  (120  or  150  cm.)  if  neces- 
sary. A  greater  pressure  than  obtained  at  the  latter  elevation  is  not 
advisable  for  fear  of  rupturing  the  bowel.  This  danger  should  be 
constantly  borne  in  mind. 

Position  of  the  Patient. — The  patient  should  be  in  the  dorsal  posi- 
tion, with  the  hips  elevated. 

Anesthesia. — Anesthesia  with  ether  to  the  full  surgical  extent  to 
produce  muscular  relaxation  is  necessary. 

Technic. — The  nozzle  or  catheter  is  well  lubricated  with  oil  or 
vaselin,  and  any  air  is  expelled  from  the  tube.  The  nozzle  is  then 
inserted  into  the  rectum  for  several  inches,  and  the  reservoir  is  ele- 
vated about  3  feet  (90  cm.)  and  the  solution  is  allowed  to  flow  slowly 
into  the  bowel.  Escape  of  the  fluid  along  the  side  of  the  tube  is 
prevented  by  tightly  packing  cotton  about  the  anus  and  pressing  the 
Ijuttocks  firmly  together.  While  the  solution  is  flowing,  the  abdomen 
may  be  very  gently  kneaded  or  the  child  may  be  inverted  several  times. 
Diminution  of  the  pressure  necessary  to  inject  the  fluid  indicates  that 
disinvagination  or  else  a  rupture  of  the  bowel  has  occurred,  and  the 
injection  should  be  immediately  stopped. 


DILATATIOX    OF    RECTAL    STRICTURES   BY    THE   BOUGIE  ::6 


:)^:) 


After  a  thorough,  trial  by  injection,  if  in  doubt  as  to  the  result,  the 
solution  is  allowed  to  escape  and  the  patient  is  examined.  If  there 
were  present  at  the  outset  a  distinct  tumor,  the  success  of  the  proce- 
dure will  be  denoted  by  its  disappearance.  A  tumor  still  present  and 
retaining  its  full  size  will,  of  course,  signify  a  failure,  and  an  immediate 
laparotomy  should  be  performed  while  the  patient  is  still  under  the 
anesthetic. 

Treatment  by  Inflation  with  Air. — In  employing  air  to  distend 
the  bowel  the  pressure  cannot  be  so  well  regulated  as  with  fluid,  and, 
furthermore,  the  weight  of  the  colunn  of  water,  which  in  some  cases 
seems  to  be  an  important  factor,  is  lacking. 

Apparatus. — A  rectal  tube  or  a  catheter  of  appropriate  size  and  an 
ordinary  bellows  or  a  Davidson  syringe  will  be  required.  In  order  to 
permit  the  escape  of  air  the  moment  it  is  desired,  a  T-tube  of  glass 
may  be  inserted  between  the  rectal  tube  and  the  inflation  apparatus. 
One  limb  of  the  T-tube  is  inserted  into  the  rectal  tube,  the  other  into 
the  tube  leading  from  the  inflator,  while  to  the  third  limb  a  short 
piece  of  rubber  tubing  is  attached  which  can  be  opened  or  shut  by  a 
clip. 

Gases  Used. — Ordinary  air,  oxygen,  or  carbonic  acid  gas  may  be 
employed. 

Pressure. — The  air  should  be  injected  very  slowly.  The  best 
guide  as  to  the  amount  to  be  introduced  and  the  pressure  is  the  dis- 
tention produced  along  the  colon  and  in  the  abdomen. 

Anesthesia.— A  general  anesthetic  should  be  employed  to  insure 
extreme  relaxation. 

Technic. — The  tube  or  catheter  is  introduced  well  into  the  rectum 
and  the  inflating  apparatus  is  connected.  The  air  is  very  gently  and 
slowly  pumped  in,  while  an  assistant  compresses  the  buttocks  to  pre- 
vent its  escape.  Gentle  abdominal  massage  or  inversion  of  the 
patient  may  be  tried  while  the  inflation  is  progressing.  Reduction 
may  be  indicated  by  rumbhng  sounds  or  a  gush  of  liquid  fecal  matter. 

DILATATION  OF  RECTAL  STRICTURES  BY  THE  BOUGIE 

The  surgical  treatment  of  rectal  strictures  consists  of :  ( i  j  Gradual 
dilatation;  (2)  proctotomy;  (3)  excision;  (4)  entero-anastomosis; 
and  (5)  colostomy.  Treatment  by  dilatation,  though  not  often  cura- 
tive, is  a  most  valuable  palliative  measure.  By  means  of  gradual 
dilatation,  the  lumen  of  a  stricture  may  be  so  much  increased  in  size 
that  the  patient  is  relieved  of  his  obstructive  symptoms  and  may  be 


566  THE  COLOX  AND  RECTUM 

kept  comfortable  for  years,  provided  the  dilatation  be  maintained  by 
the  occasional  passage  of  a  bougie. 

Exact  information  as  to  the  site,  caliber,  length,  and  thickness  of 
the  constriction  should  be  previously  obtained  by  means  ot  a  digital 
examination,  if  within  4  inches  (10  cm.)  of  the  anus,  or  if  seated 
higher  up,  by  the  use  of  the  proctoscope  and  bougie,  as  already 
described,  before  any  attempt  at  dilatation  is  made.  The  majority  of 
strictures  are  situated  within  3  inches  (7.5  cm.)  of  the  anus,  though 
they  may  De  located  at  any  point  higher  up,  or  within  the  anus  itself. 
The  stricture  may  consist  of  a  ring-like  constriction,  or  a  narrowing  of 
the  canal  for  a  distance  of  i  inch  (2.5  cm.)  or  more,  or  it  may  be  tor- 
tuous in  shape.  The  bowel  above  the  stricture  is  often  markedly 
dilated  and  the  rectal  walls  may  be  so  thinned  that  rupture  of  the  gut 
readily  occurs  upon  the  use  of  slight  force.  At  the  seat  of  stricture  the 
mucous  membrane  is  often  ulcerated  or  replaced  by  dense  scar  tissue. 

Instruments. — The  instrument  employed  for  dilatation  should  be 
a  soft-rubber  bougie  with  a  conical  tip,  such  as  the  Wales  instrument 
(Fig.  580).  Metal  dilators  and  those  of  rigid  material  should  be 
avoided  as  dangerous. 

Asepsis. — The  bougies  are  to  be  sterilized  before  using,  and  the 
bowels  should  be  well  cleaned  out,  the  rectum  being  irrigated  with 
normal  salt  solution  both  before  and  after  each  treatment. 


r^^  ^^  L_8_]  LJQ. 

Fig.  580. — Wales'  bougies. 

Rapidity  of  Dilatation. — The  stricture  should  be  stretched  gradu- 
ally. Dilatation  ought  not  to  be  performed  rapidly  or  by  divulsion. 
Such  methods  are  extremely  dangerous,  as,  apart  from  the  shock,  on 
account  of  the  laceration  of  the  tissues  there  is  great  risk  of  hemor- 
rhage and  septic  infection. 

Frequency. — This  depends  upon  the  amount  of  tenderness  and 
irritation  as  the  result  of  the  manipulations.  If  the  bougies  are 
passed  at  too  frequent  intervals,  irritation  and  inflammation  are 
produced  which  induce  the  very  condition  it  is  intended  to  correct. 
As  a  rule,  the  stretching  should  not  take  place  oftener  than  every 


DILATATION   OF   RECTAL   STRICTURES  BY   THE  BOUGIE 


567 


other  day.  In  some  cases,  the  lapse  of  two  or  three  days  between 
each  treatment  is  necessary,  for  the  bougie  ought  not  to  be  reintro- 
duced until  all  signs  of  the  discomfort  it  has  produced  have  entirely 


Fig.  581. — Method  of  inserting  a  bougie  into  a  stricture  through  a  proctoscope. 


Fig.  582. — Showing  a  bougie  passed  through  a  stricture. 


passed  off.  Later,  when  full  dilatation  has  been  reached,  an  interval 
up  to  a  month  may  elapse  between  each  treatment,  if  it  is  found  that 
there  is  no  tendency  for  the  contraction  to  recur  in  the  interval. 


568  THE    COLON    AXD   RECTUil 

Position  of  the  Patient. — The  patient  is  to  be  in  the  Sims  position, 
with  the  knees  well  drawn  up,  or  in  the  knee-chest  position  if  a  procto- 
scope is  to  be  used. 

Technic. — The  bougie  is  well  lubricated  and,  guided  by  the  right 
index-linger,  is  made  to  enter  the  orifice  of  the  constriction;  or,  better 
still,  it  is  inserted  accurately  into  the  stricture  under  the  guidance  of 
the  eye  through  a  proctoscope  introduced  to  the  seat  of  stricture  (Fig. 
581),  as  recommended  by  Tuttle.  The  advantages  of  this  method  are 
ob\'ious.  The  greatest  gentleness  must  be  observed  in  inserting  the 
bougies,  and  under  no  circumstances  should  the  tissues  be  lacerated. 
The  first  instrument  should  be  of  such  a  size  that  it  enters  the  stric- 
ture with  ease.  The  next  one.  a  size  larger,  is  left  in  place  for  a  few 
moments,  and  then  a  third  instrument  is  inserted  if  it  can  be  done 
without  pain  to  the  patient.  The  proctoscope  is  then  withdrawn  and 
the  bougie  is  left  iu  situ  ten  to  fifteen  minutes. 

Following  the  treatment,  an  irrigation  of  hot  normal  salt  solu- 
tion is  given,  and  the  patient  is  kept  quiet  for  a  quarter  to  a  half-hour. 
At  the  subsequent  sittings,  it  is  well  to  commence  with  an  instrument 
a  size  smaller  than  the  largest  one  used  at  the  previous  sitting.  An 
increase  in  the  dilatation  is  attempted  at  each  instrument. 

COLONIC  MASSAGE 

Abdominal  massage  is  indicated  for  the  relief  of  chronic  consti- 
pation and  its  accompanying  symptoms  the  result  of  the  atony  of  the 
intestines,  in  which  class  of  cases,  if  properly  carried  out,  it  is  a  most 
valuable  therapeutic  measure,  tending  to  strengthen  the  muscles  of 
the  abdomen  and  bowel  and  the  tone  of  the  nervous  system,  as  well 
as  to  stimulate  the  secretory  function  of  the  colon  and  to  increase  the 
peristaltic  action.  To  be  of  value,  however,  it  should  be  performed 
by  one  trained  for  such  work.  Massage  is  contraindicated  during 
menstruation  and  in  pregnancy,  and.  of  course,  in  the  presence  of  such 
pathological  conditions  as  gastric  or  intestinal  ulcers,  intestinal 
obstruction,  appendicitis,  hemorrhage  from  the  bowel,  inflammation 
of  the  peritoneum,  etc. 

Time  for  Massage. — The  best  time  for  massage  is  early  in  the 
morning  before  breakfast.  In  cases  where  this  is  not  possible,  care 
should  be  observed  that  it  is  not  given  until  at  least  one  hour  has 
elapsed  since  the  last  meal. 

Duration. — Each  treatment  should  consume  from  five  to  fifteen 
minutes.     The  treatments  should  be  persisted  in  until  the  regularity 


COLONIC   MASSAGE 


;6q 


Fig.  583. — Deep  pressure  colonic  massage.     (Bandler.) 


Fig.  584. — Showing  the  method  of  kneading  the  colon.      (Bandler.) 


570  THE  COLON  AND  RECTUM 

of  the  stools  is  re-established,  to  effect  which  may  require  several 
weeks  or  months. 

Frequency. — Treatments  should  be  given  daily. 

Preparations. — The  bladder  and,  if  possible,  the  rectum  should  be 
empty. 

Position  of  the  Patient. — The  patient  lies  in  the  dorsal  position 
with  the  shoulders  and  knees  slightly  elevated,  so  as  to  secure  as 
much  relaxation  as  possible. 

Technic. — The  masseur  stands  upon  the  patient's  left  side  and 
begins  his  manipulations  by  making  light  circular  movements  (effleur- 
age),  starting  at  the  cecum  and  following  the  course  of  the  ascending, 
transverse,  and  descending  colon.  The  small  intestine  and  the  rest 
of  the  abdomen  are  similarly  manipulated.  Then  deep  pressure  and 
kneading  movements  (petrissage)  are  substituted.  In  these  move- 
ments the  whole  colon  is  manipulated  in  the  first  instance  by  perform- 
ing zigzag  movements  while  making  deep  pressure  with  one  hand 
superimposed  upon  the  other  (Fig.  583),  and,  in  the  second  instance, 
by  raising  up  deep  handgrasps  of  the  abdominal  muscles  and  the 
intestines  and  kneading  them  by  alternately  compressing  and  relax- 
ing the  fingers  (Fig.  584).  In  performing  these  deeper  manipulations 
one  will  be  governed  as  to  the  amount  of  force  that  may  be  employed 
by  the  sensitiveness  of  the  patient.  Care  should  be  taken  that  the 
manipulations  be  not  too  vigorous,  lest  some  injury  to  the  viscera 
result. 

AUTO-MASSAGE 

Massage  may  be  very  effectually  carried  out  by  the  patient  him- 
self by  rolling  a  ball  over  the  abdomen,  beginning  at  the  cecum  and 


Fig.  585. — Cannon  ball  for  auto-massage  of  the  abdomen. 

following  the  course  of  the  colon  up  the  right  side,  then  across  the 
abdomen,  and  down  the  left  side  in  the  direction  of  the  descending 
colon.  A  cannon  ball  or  a  wooden  ball  filled  with  shot  weighing  3  to 
5  pounds  (1.4  to  2.2  K.),  covered  with  chamois  or  flannel  (Fig.  585), 
may  be  used  for  this  purpose. 


APPLICATION   OF   ELECTRICITY   TO   RECTUM   AND    COLON 


571 


THE  APPLICATION  OF  ELECTRICITY  TO  THE  RECTUM  AND 

COLON 

Electricity  is  of  value  in  conjunction  with  the  abdominal  massage 
in  all  forms  of  constipation,  but  especially  so  in  the  atonic  variety. 
Under  the  stimulating  action  of  the  electric  current,  the  nerves, 
muscles,  and  glandular  structures  connected  with  the  bowel  are  favor- 
ably influenced,  so  that  the  peristaltic  action  and  the  secretion  of 
mucus  are  increased,  at  the  same  time,  the  contracting  power  of  the 
voluntary  muscles  of  the  abdomen  is  strengthened. 

Both  the  faradic  and  the  galvanic  currents  are  employed,  the 
former  being  generally  preferred  for  atonic  constipation  and  intestinal 
paresis  and  the  galvanic  for  spastic  constipation  and  painful  neuroses. 
They  may  be  applied  percutaneously  or  internally. 

Apparatus. — For  the  percutaneous  applications  a  large  flat  sponge 
electrode  (Fig.  586)  and  a  small  sponge  electrode  (Fig.  587)  will  be 


Fig.  586. — Large  flat  sponge  electrode. 


required.  When  it  is  desired  to  make  internal  applications,  a  special 
irrigating  rectal  electrode,  such  as  Boas'  (Fig.  588)  or  Kemp's,  and  a 
flat  abdominal  sponge  will  be  required. 

Strength  of  Current. — As  there  is  no  means  of  estimating  the 
strength  of  the  faradic  current,  the  sensations  of  the  patient  should  be 
the  guide,  the  current  being  strong  enough  to  cause  muscular  contrac- 
tions but  no  pain.  For  galvanism,  from  10  to  15  ma.  of  current  are 
ordinarily  required. 


0/ 


THE    COLON    AND    RECTUM 


Duration  of  Application. — Each  treatment  should  consume  from 
ten  to  fifteen  minutes. 

Frequency. — At  first  applications  are  made  daily,  then  every  other 
day,  and,  as  the  conditions  improve,  once  or  twice  a  week. 

Time  of  Application. — Treatments  are  given  with  best  results  at 
night,  just  before  the  patient  retires. 


Fig.  587. — Small  sponge 
electrode.      (Bandler.) 


Fig.  588. — Boas'  rectal  electrode.      (Bandler.) 


Position  of  Patient. — The  patient  should  be  in  the  recumbent 
position,  with  the  head  sUghtly  elevated  and  the  legs  flexed,  so  as  to 
relax  the  abdominal  muscles. 

Technic. — i.  Percutaneous  Application. — The  positive  pole  is  at- 
tached to  a  large  flat  electrode,  and  the  latter,  well  moistened,  is 
placed  over  the  spinal  column.  The  negative  electrode  is  then 
appHed  to  the  abdomen  for  a  few  minutes  at  a  time,  first  over  the 
cecum,  then  along  the  course  of  the  transverse  colon,  and  finally 
along  the  descending  colon.  This  is  supplemented  by  circular 
motions  with  the  negative  electrode  over  the  same  regions.  Finally, 
the  entire  abdomen  is  similarlv  treated. 


APPLICATION    OF    ELECTRICITY    TO    RECTUM   AND    COLON  573 

2.  Rectal  Application. — An  irrigating  electrode  attached  to  the 
negative  pole  of  the  battery  is  inserted  in  the  rectum  and  the  positive 
electrode  is  placed  over  the  spine  or  abdomen.  When  the  current  is 
turned  on,  saline  solution  is  allowed  to  flow  slowly  through  the  rectal 
electrode,  carrying  the  current  to  all  portions  of  the  colon. 


CIL\PTER  XIX 
THE  URETHRA  AND  PROSTATE 

Anatomic  Considerations 

The  Male  Urethra. — The  urethra  is  a  dosed  canal,  composed  of 
erectile  and  muscular  tissue,  and  lined  by  mucous  membrane,  extend- 
ing from  the  bladder  to  the  external  urinary  meatus.  Its  entire 
ength  is  from  6  1/2  to  9  inches  (16  to  23  cm.),  depending  upon  the 


Fig.  589. — Section  of  penis,  bladder,  etc.  (Testut.)  i,  Symphysis  pubis; 
2,  prevesical  space;  3,  abdominal  wall;  4,  bladder;  5,  urachus;  6,  seminal  vesicle 
and  vas  deferens;  7,  prostate;  8,  plexus  of  Santorini;  9,  sphincter  vesicae;  10, 
suspensory  ligament  of  penis;  li,  penis  in  flaccid  condition;  12,  penis  in  state  of 
erection;  13,  glans  penis;  14,  bulb  of  urethra;  15,  cul-de-sac  of  bulb,  a,  Prostatic 
urethra;  b,  membranous  urethra;  c,  spong}'  urethra. 

length  of  the  penis.  For  purposes  of  description  it  is  divided  into 
the  following  portions,  corresponding  to  the  parts  through  which  it 
passes:  (i)  The  spongy  portion,  or  pars  cavernosa,  (2)  the  membran- 
ous portion,  or  pars  membranosa.  and  (3)  the  prostatic  portion,  or  pars 
prostatica   (Fig.    589).     Clinically  and  for  all  practical  purposes, 

574 


ANATOMIC    CONSIDERATIONS 


575 


however,  it  may  be  divided  into  the  anterior  urethra,  that  portion 
lying  in  front  of  the  anterior  layer  of  the  triangular  ligament;  and  the 
posterior  urethra,  the  portion  lying  behind  the  anterior  layer  of  the 
triangular  ligament. 

The  Spongy  Urethra. — It  extends  the  entire  length  of  the  corpus 
spongiosum  opening  externally  upon  the  glans  penis  as  a  vertical  slit, 
the  meatus.  The  spongy  urethra  measures  on  the  average  about  6 
inches  (15  cm.).  The  lumen  of  this  portion  of  the  urethra  is  not  of 
the  same  size  throughout,  but  presents  two  fusiform  dilatations,  one 
at  the  bulb,  the  bulbous  urethra,  and  the  other  within  the  glans,  the 
fossa  navicularis. 

The  mucous  membrane  is  pale  pink  in  color  and  has  opening  upon 
its  surface  a  number  of  glands  and  crypts.  In  the  floor  of  the  bulbous 
portion  the  ducts  of  Cowper's  glands  open  side  by  side.  Scattered  all 
through  the  mucous  membrane  of  the  urethra  are  the  urethral  glands 
or  glands  of  Littre.  Upon  the  roof,  the  mucous  membrane  is  studded 
with  small  crypts  or  diverticula,  the  lacunae.  The  orifices  of  these 
lacunae  open  toward  the  meatus  forming  little  pockets  into  which 
instruments  may  find  their  way  and  be  arrested  in  their  passage. 
One  of  these,  the  lacuna  magna,  is  especially  liable  to  interfere  with 
the  passage  of  instruments.  It  Kes  in  the  roof  of  the  fossa  navicularis 
about  I  inch  (2.5  cm.)  from  the  meatus.  These  mucous  glands  and 
lacunas  are  liable  to  infection  and  may  become  the  seat  of  small  gonor- 
rheal abscesses. 


Fig.  590. ^The  interior  of  the  urethra,  i,  Meatus;  2,  fossa  navicularis;  3, 
urethral  glands;  4,  orifices  of  Cowper's  glands;  5,  Cowper's  glands;  6,  ejaculatory 
ducts;  7,  sinus  pocularis;  8,  verumontanum. 


The  Membranous  Urethra. — It  is  that  portion  of  the  urethra 
lying  between  the  two  layers  of  the  triangular  ligament,  and  extends 
from  the  apex  of  the  prostate  gland  to  the  bulb  of  the  spongy  portion. 
It  measures  about  1/2  inch  (i  cm.)  in  length.  The  membranous  ure- 
thra is  the  most  fixed,  as  well  as  the  least  distensible  of  all  segments  of 
the  urethra.  In  its  course  it  pierces  both  layers  of  the  triangular  Hga- 
ment  and  receives  prolongations  from  these  structures,  and  is  also 


^76  THE    URETHRA    AND   PROSTATE 

surrounded  by  the  compressor  urethrse  muscle.  Spasm  of  this  muscle 
is  a  frequent  hindrance  to  catheterization  and  the  passage  of  sounds. 
Embedded  in  the  libers  of  the  compressor  urethrse  and  on  either  side 
of  the  membranous  urethra  He  the  glands  of  Cowper,  the  ducts  from 
which  open  in  the  anterior  portion  of  the  bulbous  urethra. 

The  mucous  membrane  lining  this  portion  of  the  canal  is  darker 
in  color  and  much  more  sensitive  than  that  in  the  spongy  portion. 

Prostatic  Urethra. — It  measures  3/4  to  i  1/4  inches  (2  to  3  cm.) 
in  length  and  extends  from  the  internal  urethral  orifice  to  the  posterior 
layer  of  the  triangular  ligament,  traversing  the  prostate  gland  from 
base  to  apex.  In  the  presence  of  hypertrophy  of  the  prostate,  the 
caliber  of  this  portion  of  the  canal  may  become  obstructed  or 
deformed. 

The  floor  of  the  prostatic  urethra  is  encroached  upon  by  a  fusiform 
swelling,  the  verumontanum  or  caput  galHnaginis.  At  the  front  and 
most  prominent  part  of  the  verumontanum  is  seen  the  slit-like  open- 
ing of  the  sinus  pocularis,  a  blind  pouch  or  diverticulum,  usually  1/4  to 
1/3  inch  (6  to  8  mm.)  in  length,  which  runs  up  in  the  substance  of  the 
prostate  beneath  the  middle  lobe.  It  is  regarded  as  homologous  with 
the  uterus  in  the  female.  Within  the  sinus  pocularis  or  upon  its 
margins  are  the  slit-like  openings  of  the  ejaculatory  ducts.  On  each 
side  of  the  verumontanum  is  a  depression,  the  prostatic  sinus  into 
which  the  openings  of  the  prostatic  ducts  empty. 

The  Caliber  of  the  Urethra. — The  caliber  of  the  urethra  varies 
greatly.  While  the  average  diameter  is  0.3  inch  (7.5  mm.)  or  27 
French  scale,  the  individual  urethra  is  not  of  the  same  uniform  cali- 
ber from  end  to  end,  there  being  a  number  of  constricted  and  dilated 
portions.  The  wide  parts  are:  (i)  The  pars  prostatica,  (2)  the  bulb- 
ous urethra,  and  (3)  the  fossa  navicularis.  The  narrow  portions 
are:  (i)  The  meatus,  (2)  the  penoscrotal  junction,  (3)  the  membran- 
ous urethra,  and  (4)  the  internal  prostatic  opening.  Of  these  the 
meatus  is  the  narrowest,  and  in  a  normal  individual  an  instrument 
that  will  pass  the  meatus  should  pass  the  other  narrow  points. 

Normally,  the  walls  of  the  urethra  are  in  contact  and  on  cross 
section  the  canal  appears  as  a  mere  slit.  In  the  prostatic  portion, 
from  the  projection  of  the  verumontanum,  it  has  the  appearance  of  a 
half  moon,  in  the  membranous  portion  it  is  star-shaped;  in  the  cav- 
ernous portion,  it  appears  as  a  transverse  sHt;  in  the  glans,  as  a  verti- 
cal slit. 

Curves  of  the  Urethra. — The  anterior  urethra  is  freely  movable 
and  may  be  made  to  assume  any  curve.     The  posterior  urethra  is 


ANATOMIC   CONSIDERATIONS  577 

fixed,  however,  between  the  suspensory  hgament  of  the  penis  and  the 
internal  vesical  opening,  and  its  natural  curves  are  important  to  bear 
in  mind  in  the  passage  of  instruments.  In  the  prostatic  portion  the 
direction  of  the  urethra  is  downward;  in  the  membranous,  downward 
and  forward;  and  in  the  spongy  portion,  forward  and  slightly  upward 
for  2  inches  (5  cm.),  and  then  sharply  downward.  Thus  two  curves 
are  formed:  (i)  concave  forward,  and  (2)  concave  downward.  The 
latter  may  be  straightened  or  obliterated  by  lifting  up  the  penis,  but 
the  first  is  fixed  and  can  only  be  straightened  by  using  some  force.  In 
children  and  in  thin  individuals,  the  fixed  curve  is  much  sharper, 
while  in  large,  stout  men  it  becomes  flattened.  A  distended  bladder 
or  an  enlarged  prostate  lengthens  it. 

The  Female  Urethra. — It  extends  from  the  neck  of  the  bladder 
to  the  external  urinary  meatus,  curving  downward  and  a  little  forward. 
The  female  urethra  measures  i  1/4  to  i  1/2  inches  (3  to  4  cm.)  in 
length  and  1/4  inch  (6  mm.)  in  diameter,  but,  as  it  is  not  surrounded 
by  resisting  structures,  it  is  possible  to  so  dilate  it  as  to  admit  the 
finger.  It  lies  in  front  of,  and  is  very  closely  associated  with,  the 
anterior  wall  of  the  vagina  through  which  it  may  be  readily  palpated. 

Its  walls,  composed  of  muscular,  erectile,  and  mucous  tissue,  are 
normally  in  contact,  presenting  a  stellate  appearance  on  cross  section. 
The  mucous  membrane  is  pale  in  color  and  is  thrown  into  a  series  of 
longitudinal  folds,  one  of  which,  on  the  upper  half  of  the  posterior 
wall,  is  quite  marked  and  corresponds  to  the  verumontanum  in  the 
male.  The  compressor  urethrse  muscle  surrounds  it,  between  the 
layers  of  the  triangular  ligament. 

Close  to  the  posterior  margin  of  the  external  urethral  orifice  on 
either  side  of  the  mid-line  are  the  tubes  of  Skene.  As  in  the  male,  the 
external  meatus  is  the  narrowest  portion.  It  appears  as  a  vertical 
slit  1/5  to  1/4  inch  (5  to  6  mm.)  in  length,  about  i  inch  (2.5  cm.) 
posterior  to  the  base  of  the  clitoris. 

The  Prostate  Gland. — The  prostate  is  a  sexual  organ  composed 
of  glandular,  muscular,  and  fibrous  tissue,  lying  in  front  of  the  neck  of 
the  bladder.  It  is  pierced  above  by  the  urethra  and  below  by  the 
ejaculatory  ducts.  In  shape  it  resembles  an  irregular  truncated  cone, 
the  apex  of  which  rests  against  the  posterior  layer  of  the  triangular 
ligament  while  the  base  is  directed  toward  the  bladder.  In  size  it 
measures  about  i  1/2  inches  (4  cm.)  transversely,  i  1/4  inches  (3  cm.) 
vertically,  and  3/4  inch  (2  cm.)  longitudinally.  It  weighs  4  to  6 
drams  (16  to  24  gm.).  The  size  of  the  prostate  is  not  constant,  how- 
ever, varying  greatly  in  different  individuals  and  depending  upon  the 
37 


;78 


THE    URETHRA   AND   PROSTATE 


age  of  the  patient.  In  a  child,  the  gland  is  only  rudimentary,  not 
reaching  the  full  size  until  about  the  twenty-fifth  year.  During  the 
later  years  of  life,  it  often  becomes  hypertrophied,  not  infrequently 
enlarging  to  over  twice  its  original  size. 

The  prostate  consists  of  two  lateral  lobes  which  bulge  posteriorly 
and  a  so-called  middle  lobe.  The  latter  is  that  portion  of  the  gland 
which  lies  between  the  two  ejaculatory  ducts  directly  posterior  to  the 
beginning  of  the  urethra.  If  enlarged,  as  occurs  when  the  gland  is  the 
seat  of  senile  hypertrophy,  the  median  lobe  forms  a  projection  which 


Fig.  591. — The  prostate  gland  and  seminal  vesicles. 

may  cause  urinary  obstruction  and  interfere  with  the  passage  of 
instruments.  The  two  lateral  lobes  meet  and  become  continuous  in 
front  and  behind  the  urethra.  The  tissue  forming  this  union  in  front 
is  spoken  of  as  the  anterior  commissure  and  the  portion  behind  as  the 
posterior  commissure  or  isthmus  (pars  intermedia). 


Diagnostic  Methods 

In  the  examination  of  the  urethra  some  definite  system  should  be 
followed.  The  first  step  consists  in  taking  a  careful  history  of  the 
case.  This  should  embrace  the  family  history,  a  history  of  past  ail- 
ments, and  the  patient's  description  of  the  present  trouble,  its  onset, 
duration,  etc.  While  in  some  cases  of  urethral  disease  exhaustive 
questioning  of  the  patient  is  superfluous,  it  will  be  found  that  an  exact 


GLASS    TESTS  579 

history  will  often  be  of  the  greatest  aid  in  arriving  at  a  correct 
diagnosis. 

The  examiner  should  then  take  up  more  in  detail  the  symptoms 
complained  of  by  the  patient.  It  should  be  ascertained  whether  the 
patient  has  or  has  had  a  urethral  discharge,  and,  if  so,  its  character; 
whether  it  is  sufficient  to  stain  or  stiilen  the  linen,  or  whether  it  simply 
glues  the  hps  of  the  meatus  together;  w^hether  it  occurs  only  with  the 
first  urine  passed,  or  in  the  intervals  as  w^ell;  whether  there  is  any  dis- 
charge with  defecation;  also  whether  defecation  is  accompanied  by 
pain  about  the  prostate  or  rectum.  It  is  important  to  inquire  into  the 
act  of  urination,  ascertaining  whether  the  passage  of  urine  causes  any 
pain,  and,  if  so,  its  character,  and  whether  the  pain  is  present  at  the 
beginning  or  end  of  the  act;  also  whether  there  is  an  increased  fre- 
quency in  urination.  The  patient  should  be  questioned  as  to  the 
character  of  the  stream  of  urine,  its  force  and  cahber;  whether  there  is 
any  dribbling;  whether  the  stream  is  interrupted  or  suddenly  stopped, 
such  as  would  be  the  case  with  enlargement  of  the  prostate  or  in  the 
presence  of  a  vesical  calculus.  The  character  of  the  urine  passed 
should  also  be  inquired  into;  whether  the  presence  of  blood  has  been 
noted,  and  whether  shreds  are  present,  and  their  character.  More 
exact  information  upon  these  latter  points,  however,  will  be  obtained 
after  a  complete  examination  of  the  urine. 

Having  questioned  the  patient  along  the  lines  above  indicated, 
secretions  and  discharges,  if  present,  should  be  collected  for  examina- 
tion (see  pages  231,  581),  and  then  the  actual  examination  of  the 
urethra  and  prostate  may  be  taken  up.  The  methods  available  for 
this  include:  (i)  glass  tests  and  injection  tests  for  the  purpose  of  locat- 
ing the  seat  of  the  discharge,  (2)  inspection,  (3)  palpation,  and  (4) 
instrumental  examination.  The  use  of  instruments,  however,  should 
not  he  undertaken  if  there  is  an  active  discharge  from  the  urethra  for 
fear  of  aggravating  the  inflammation  and  producing  such  complica- 
tions as  abscess,  stricture,  etc.  It  is  far  better  to  postpone  such  ex- 
ploration until  the  severity  of  the  inflammation  and  the  discharge 
have  been  reduced  by  the  use  of  injections  or  irrigations. 

GLASS  TESTS 

A  number  of  tests  have  been  employed  for  the  purpose  of  deter- 
mining whether  the  seat  of  the  pus  has  its  origin  in  the  anterior  or 
posterior  urethra.     The  simplest  of  these  are  known  as  the  two-glass 

test  and  the  three-glass  test. 


580  THE    URETHRA   AND   PROSTATE 

The  Two=glass  Test. — It  is  performed  as  follows:  The  patient  is 
instructed  to  hold  his  urine  for  three  or  four  hours,  and  upon  present- 
ing himself  for  examination  he  is  told  to  urinate  into  two  glasses  or 
graduates.  He  should  pass  about  2  ounces  (60  c.c.)  into  the  first  glass 
and  the  remainder  into  the  second.  If  the  contents  of  the  first  glass, 
in  which  are  collected  the  washings  from  both  the  anterior  and  poste- 
rior urethra,  contains  pus  or  shreds  revealed  by  holding  the  glass  be- 
fore a  strong  light  and  the  contents  of  the  second  glass  is  clear,  it  may 
be  inferred  that  the  anterior  urethra  is  involved,  but  the  posterior 
urethra,  if  at  all,  only  slightly  so.  If,  on  the  other  hand,  the  contents 
of  both  glasses  are  cloudy  or  contain  shreds,  it  shows  that  there  is  suffi- 
cient secretion  from  the  posterior  urethra  to  have  escaped  into  the 
bladder  and  discolored  its  contents,  or  that  the  secretion  comes  from 
the  bladder  itself,  the  ureters,  or  kidneys.  In  the  former  case,  the 
contents  of  the  first  glass  is  more  turbid  than  that  in  the  second  glass; 
while  in  the  latter  conditions  there  is  but  little  difference  between  the 
two  specimens. 

Another  method  and  one  that  is  more  certain  in  differentiating 
between  an  anterior  and  posterior  urethritis,  consists  in  first  thor- 
oughly irrigating  the  anterior  urethra  with  a  warm  boric  acid  or 
normal  salt  solution  by  means  of  a  catheter  introduced  as  far  as  the 
bulb,  and  then  having  the  patient  urinate  into  two  glasses.  If  the 
contents  of  both  glasses  are  clear,  we  may  be  sure  the  posterior  ure- 
thra is  free.  Pus  or  shreds  appearing  in  the  second  glass  indicate  a 
posterior  urethritis,  or  that  they  come  from  the  bladder  or  beyond. 

The  Wolbarst  Three=glass  Test. — This  is  more  rehable  than 
the  two-glass  test,  and  is  also  employed  for  the  purpose  of  determining 
whether  the  seminal  vesicles  are  inflamed.  The  technic  is  as  follows: 
The  anterior  urethra  is  washed  out  with  sterile  water  until  the  wash- 
ings return  clear.  These  washings  are  collected  in  the  first  glass  and 
represent  the  contents  of  the  anterior  urethra.  A  soft  catheter  is  next 
introduced  into  the  bladder  and  a  sample  of  its  contents  is  drawn  oft' 
into  a  second  glass.  This  represents  the  bladder  urine.  If  this 
specimen  proves  to  be  clear  and  free  from  shreds,  the  catheter  is  re- 
moved and  the  patient  is  instructed  to  void  a  little  urine  into  a  third 
glass.  This  glass  represents  the  contents  of  the  posterior  urethra.  If 
it  should  be  found,  however,  that  the  contents  of  the  second  glass  is 
not  clear,  that  is,  if  the  bladder  urine  is  cloudy,  the  catheter  is  left  in 
place  and  the  bladder  is  emptied  and  is  then  washed  out  with  sterile 
water,  allowing  from  4  to  6  ounces  (120  to  180  c.c.)  of  clear  solution  to 
remain.     The  catheter  is  then  removed  and  the  test  is  carried  out  as 


INSPECTION  551 

before  for  the  third  glass.  The  prostate  and  seminal  vesicles  are  next 
massaged  and  the  patient  then  voids  the  urine  or  solution  containing 
pus  expressed  from  the  prostate  and  seminal  vesicles  into  a  fourth 
glass. 

INJECTION  TEST 

For  the  purpose  of  differentiating  between  an  anterior  and  a  pos- 
terior urethritis,  the  anterior  urethra  may  be  injected  with  a  solution 
that  "will  color  the  shreds  in  that  portion  of  the  canal.  A  i  per  cent, 
solution  of  methylene  blue  is  employed.  By  means  of  a  blunt-pointed 
urethral  syringe  the  anterior  urethra  is  filled  with  the  methylene  blue 
and  the  patient  is  instructed  to  hold  the  solution  in  the  urethra  for 
about  a  minute.  The  solution  is  then  allowed  to  escape.  If  upon 
urination  the  shreds  appear  blue,  they  come  from  the  anterior  urethra; 
unstained  shreds  from  the  posterior  urethra.  A  microscopical  exami- 
nation may  be  necessary,  however,  to  determine  whether  the  shreds 
remain  unstained.  In  making  this  test  it  is  essential  that  the  patient 
should  not  have  urinated  for  some  time  previously. 

INSPECTION 

In  the  Male. — In  the  male,  inspection  of  the  urethra  without 
the  aid  of  instruments  is  limited  to  the  meatus  and  the  exterior  of  the 

canal  as  far  as  the  peno-scrotal  junction.  Swelling,  signs  of  inflam- 
mation, new  growths,  etc.,  which  present  externally  may  thus  be 
recognized.  While  comparatively  limited  in  scope,  inspection  should 
never  be  neglected,  but  should  form  part  of  the  routine  examination. 

Position  of  Patient. — The  patient  may  stand  or  lie  flat  upon  a 
table. 

Technic. — The  penis  is  elevated  so  as  to  bring  its  under  surface  to 
view  and  any  abnormalities  are  noted.  The  presence  or  absence  of  a 
discharge  should  also  be  determined.  By  stripping  the  urethra  from 
the  scrotum  forward  by  means  of  the  index-finger  applied  ejJternally, 
the  presence  of  any  discharge  may  be  demonstrated.  If  present,  some 
should  be  deposited  upon  a  slide,  and  later  should  be  stained  and 
examined  for  gonococci. 

In  the  Female.  — In  the  female,  the  mouth  and  the  vaginal  sur- 
face of  the  canal  in  its  entire  course  may  be  inspected. 

Position  of  Patient. — The  patient  should  be  placed  in  the  dorsal 
position. 

Technic. — The  operator,  sitting  in  front,  separates  the  labia  and 


582 


THE    URETHRA    AND    PROSTATE 


notes  the  condition  of  the  meatus  and  searches  for  signs  of  inflamma- 
tion, the  presence  of  new  growths,  eversion  of  the  mucous  membrane, 
discharges,  etc.  The  presence  of  the  latter  may  be  more  readily  dem- 
onstrated by  stripping  the  canal  from  the  bladder  forward  by  means 
of  a  finger  passed  into  the  vagina  (Fig.  592).  The  mouth  of  the  ure- 
thra may  be  exposed  by  drawing  the  lips  apart  by  means  of  the 
fingers,  one  placed  on  each  side  as  shown  in  Fig.  593.  In  this  manner 
the  orifices  of  Skene's  glands  may  be  exposed.  Finally,  the  index- 
finger  or  a  speculum  is  passed  into  the  vagina  and  its  posterior  wall  is 
depressed,  so  that  the  whole  extent  of  the  vaginal  surface  of  the  ure- 
thra is  exposed.  In  this  manner  tumors,  dilatations,  cysts,  saccula- 
tions, etc.,  will  be  noted. 


Fig.  592. — Method  of  stripping  a  dis- 
charge from  the  urethra.     (Ashton.) 


Fig.  593. — Method   of    inspecting   the 

urethral  orifice  in  the  female. 

(Ashton.) 


PALPATION 

In  the  Male. — ^Like  inspection,  palpation  of  the  urethra  is  of 
limited  value,  especially  in  the  male.  By  it,  however,  changes  in  the 
consistency,  sensitiveness,  and  form  of  the  canal  may  be  recognized. 

Position  of  Patient. — The  urethra  may  be  palpated  with  the 
patient  standing  or  in  the  dorsal  position.  To  palpate  the  prostate 
the  patient  should  be  placed  in  the  knee-chest  position,  or  should  bend 
over  with  the  hands  resting  upon  a  chair  and  the  thighs  separated. 

Technic. — In  palpating  the  urethra  the  penis  should  be  grasped 
just  behind  the  glans  between  the  thumb  and  forefinger  of  the  left 
hand,  and,  while  putting  the  organ  on  the  stretch,  the  penile  portion 


PALPATION 


583 


of  the  urethra  is  palpated  between  the  thumb  and  forefinger  of  the 
right  hand  (Fig.  594).  It  should  be  noted  whether  the  urethra  is 
elastic,  as  it  normally  is,  or  whether  it  is  hard,  indurated,  or  nodular. 
An  inflamed  urethra  will  be  painful  to  the  touch  and  will  feel  tense  and 


Fig.  594. — External  palpation  of  the  urethra. 


Fig.  595. — Showing  the  method  of  palpating  the  prostate  gland. 

swollen.  A  urethral  abscess  appears  as  a  painful  swelling  bulging 
the  wall  of  the  canal.  A  cancerous  growth  will  be  hard,  nodular,  and 
adherent.  By  inserting  a  sound  and  then  palpating  the  urethra  upon 
it  more  valuable  information  may  be  obtained,  as  changes  in  the 
consistency  of  the  canal  will  be  accentuated. 


584 


THE    URETHRA   AND   PROSTATE 


To  palpate  the  membranous  urethra  and  prostate  a  rectal  exami- 
nation will  be  necessary.  For  this  the  bladder  should  preferably 
contain  a  little  urine.  The  operator,  standing  upon  the  patient's  left, 
inserts  his  right  forefinger,  protected  by  a  finger  cot  and  well  lubricated, 
into  the  bowel  (see  Palpation  of  the  Rectum,  page  527).  After  pass- 
ing the  sphincter,  the  examining  finger  comes  in  contact  with  the  mem- 
branous urethra  for  a  space  of  1/2  inch  (i  cm.),  and  then  the  pros- 
tate gland  is  reached.  Normally,  the  latter  is  not  very  distinctly 
felt,  but  in  the  presence  of  hypertrophy  it  readily  is,  and  sometimes 
it  is  so  enlarged  that  it  may  be  palpated  bimanually.  Points  of  ten- 
derness, softening,  painful  swellings,  or  a  general  enlargement  should 
be  looked  for  and  any  difference  between  the  two  lobes  should  be 
noted.  The  condition  of  the  seminal  vesicles  should  likewise  be 
investigated.  They  lie  above  each  lobe  of  the  prostate  extending 
upward  and  outward,  but  are  not  palpable,  unless  enlarged  or 
thickened  bv  disease. 


Fig.  596. — Combined  rectal  and  instrumental  examination  of  the  prostate  gland. 


If  desired,  the  seminal  vesicles  and  prostate  may  at  this  time  be 
massaged  for  the  purpose  of  obtaining  their  secretions  for  examina- 
tion. This  is  done  by  carrying  the  finger  up  over  each  seminal  vesicle 
in  turn  and,  while  making  firm  pressure,  carrying  the  finger  downward 
over  the  lobe  of  the  prostate  toward  its  base.  The  massage  will 
force  the  discharge  into  the  urethra  and  it  may  then  be  collected 
upon  a  clean  slide  by  stripping  the  urethra  from  behind  forward. 


EXAMINATION  BY    SOUNDS   AND  BOUGIES  585 

At  times  a  combined  examination  with  the  finger  in  the  rectum 
and  an  instrument  in  the  urethra  will  be  of  assistance  in  exploring  the 
prostate.  A  bladder  sound  or  other  metallic  instrument  is  introduced 
into  the  bladder,  and,  by  engaging  the  prostate  between  it  and  the 
examining  finger  (Fig.  596),  the  extent  of  hypertrophy  as  well  as  the 
amount  of  induration  may  be  ascertained. 

In  the  Female. — In  the  female,  the  entire  canal  may  be  ex- 
plored by  palpation  through  the  vagina  and  valuable  information 
is  thus  often  obtained. 

Position  of  Patient. — The  patient  is  placed  in  the  dorsal  position. 

Technic. — The  examiner,  sitting  in  front,  separates  the  labia  with 
the  fingers  of  his  left  hand,  while  he  palpates  with  his  right  index- 
finger.  The  meatus  is  first  examined  by  pressing  with  the  examining 
finger  placed  just  outside  the  vaginal  outlet  up  against  the  symphysis. 
Then  by  means  of  the  index-finger  in  the  vagina  the  whole  length  of 
the  urethra  may  be  explored  by  tracing  the  course  of  the  canal  back  as 
far  as  the  bladder.  By  rolling  the  urethra  with  the  index-finger  from 
side  to  side  and  exerting  pressure  upward  upon  the  canal  with  the 
inferior  and  posterior  surfaces  of  the  symphysis  as  points  of  counter- 
pressure,  changes  as  to  sensitiveness,  consistency,  or  form  of  the  canal 
may  be  readily  recognized. 

EXAMINATION  BY  SOUNDS  AND  BOUGIES 

Having  obtained  all  the  information  possible  by  the  means  already 
detailed,  an  instrumental  exploration  of  the  urethra,  provided  the  latter 
is  not  the  seat  of  an  acute  inflammation,  for  the  purpose  of  determining 
the  presence  or  absence  of  strictures  is  the  next  step.  While  such 
symptoms  as  a  gleety  discharge,  dribbling  at  the  end  of  urination, 
malformation  in  the  shape  of  the  stream,  difficulty  in  starting  the 
stream,  retention  of  urine,  etc.,  may  point  strongly  to  the  presence 
of  a  stricture,  they  are  by  no  means  infallible,  and  it  is  only  by  a  care- 
ful local  examination  of  the  urethra  that  the  diagnosis  of  stricture  can 
be  absolutely  made.  For  the  purpose  of  simply  locating  a  stricture 
and  determining  its  size,  sounds  and  bougies  are  employed,  while  for 
determining  the  length  of  the  contracture  the  bulbous  bougie  or 
bougie  a  boule  is  necessary. 

In  inserting  an  instrument  into  the  urethra,  the  utmost  gentleness 
is  required.  The  instrument  should  be  passed  slowly  so  that,  if  an 
obstruction  is  suddenly  encountered,  there  will  be  no  danger  of  pro- 
ducing injury  to  the  canal;  even  the  slightest  force  should  always  he 


S86 


THE    URETHRA    AND    PROSTATE 


avoided.  It  is  only  by  cultivating  a  delicate  touch  and  keeping  in 
mind  the  anatomical  variations  in  the  urethra  that  painless  manipu- 
lation of  urethral  instruments  is  possible.  In  making  such  an  exam- 
ination it  should  be  remembered  that  the  passage  of  an  instrument 


Fig.  597. — Blunt  steel  sound. 

for  the  first  time  may  result  in  a  severe  chill,  and  a  rise  of  tempera- 
ture. To  prevent  this,  it  is  well  to  terminate  the  examination  with  an 
instillation  of  i  to  1500  nitrate  of  silver  to  lessen  the  urethral  conges- 
tion.    After  one  exploration  the  urethra  should  be  given  a  rest  for  a 


Fig.  598. — Flexible  urethral  bougie. 

few  days,  as  not  infrequently  the  irritation  produced  aggravates  a 
chronic  urethral  discharge. 

Instruments. — Blunt  steel  sounds  of  the  proper  curve  (Fig.  597) 
are  preferable  for  the  exploration  of  strictures  of  large  caliber.     There 


\. 


Fig.  599. — Filiform  bougies. 

is  considerable  risk  of  injuring  the  urethra  when  a  rigid  steel  instru- 
ment of  a  size  smaller  than  15  French  is  used,  and  it  is  safer  for  those 
not  especially  skilled  in  the  manipulation  of  urethral  instruments 
to  employ  woven-silk  olivary  bougies  (Fig.  598)  in  examining  small 


Fig.  600. — Female  sound.     (Ashton.) 

strictures.  A  set  of  these  instruments  from  the  smallest  size  made 
up  to  No.  20  French  should,  therefore,  be  at  hand.  The  best  are 
made  in  France.  For  finding  the  channel  through  very  tight  stric- 
tures whalebone  filiform  bougies  (Fig.  599)  are  necessary.     They  are 


EXAMINATION  BY    SOUNDS   AND  BOUGIES 


587 


provided  with  small  bulbous  points  from  which  they  taper  for  an  inch 
(2.5  cm.)  or  so  until  the  full  size  of  the  shaft  is  reached.  To  facilitate 
the  entrance  of  these  instruments  into  tortuous  canals  the  tips  may 
be  softened  in  hot  water  and  then  bent  into  various  shapes,  as  curves, 
spirals,  angles,  etc.  For  diagnostic  purposes  the  filiforms  should  be 
about  12  inches  long  (30  cm.).  For  exploring  the 
female  urethra  a  slightly  curved  steel  sound  is 
employed  (Fig.  600). 

Asepsis. — Metal  instruments  are  boiled  for 
five  minutes  in  a  i  per  cent,  soda  solution.  The 
best  makes  of  the  silk-elastic  instruments  may 
also  be  boiled,  but  some  of  the  others  will  not 
last  long  if  so  treated,  and  it  is  safer  to  sterilize 
them  in  formalin  vapor  for  twenty-four  hours  and 
then  rinse  well  in  sterile  water  before  using.  A 
special  apparatus  (Fig.  601)  is  required  for  this, 
however.  It  consists  of  a  glass  cylinder  about  16 
inches  (40  cm.)  long  with  a  perforated  plate  near 
the  top  for  holding  the  catheters  and  in  the  base  a 
receptacle  for  formalin  tablets.  In  its  absence 
the  instrument  may  be  soaked  in  a  i  to  20  car- 
bolic acid  solution'  followed  by  immersion  in  a 
saturated  boric  acid  solution  and  rinsing  in  sterile 
water.  Whalebone  bougies  may  be  boiled,  though 
they  will  not  stand  prolonged  boiling.  The  ex- 
aminer's hands  should  be  as  carefully  cleansed  as 
.  .  Fig.    601. — Form- 

for  any  operation.^  ^      ^li„     sterilizer     for 

The  glans  penis  should  be  first  washed  with  urethral  instruments. 
soap  and  water,  then  with  a  i  to  5000  bichlorid      ^'    '^°P'    *'   ^^'^^ 

for  03 l^iif topi's '  c    ooTT"" 

solution  followed  by  sterile  water.     The  urethra  ^^.^^^  ^^^  formalin. 
is  irrigated  with  a  warm  saturated  solution  of 
boric  acid  or  with  a  i  to  5000  solution  of  potassium  permanganate 
both  before  and  after  the  examination. 

Position  of  Patient. — The  patient  should  lie  in  the  dorsal  position 
with  his  shoulders  slightly  raised  and  thighs  flexed  and  rotated  some- 
what outward,  and  near  that  side  of  the  table  upon  which  the  opera- 
tor stands.  The  operator  takes  his  place  just  above  the  patient's  hips, 
facing  the  patient's  body,  upon  whichever  side  of  the  table  is  most 
convenient  for  him — generally  the  left  side  is  chosen. 

Technic. — In  beginning  the  examination  the  largest  instrument 
that  will  pass  the  meatus  should  be  introduced.     As  the  meatus  is  the 


588 


THE   URETHRA   AND   PROSTATE 


narrowest  portion  of  the  urethra,  any  instrument  that  can  be  intro- 
duced through  it  will  pass  along  the  entire  canal,  unless  some  con- 
traction is  present.     Should  the  meatus  be  abnormally  small,  it  may 


Fig.  602. — First  step  in  inserting  a  urethral  sound. 

be  enlarged  by  an  incision  (see  page  626).  The  operator  grasps  the 
penis  behind  the  corona  between  the  ring  and  middle  fingers  of  the 
left  hand  and  with  the  thumb  and  index-fingers  of  the  same  hand  he 
retracts  the  foreskin  and  separates  the  lips  of  the  meatus.  The  sound, 
warmed  and  well  lubricated  with  one  of  the  Irish-moss  preparations. 


Fig.  603. — Second  step  in  inserting  a  urethral  sound. 

is  grasped  lightly  between  the  fingers  of  the  right  hand,  and  is  gently 
introduced  into  the  meatus.  As  the  point  of  the  instrument  is  in- 
serted in  the  meatus  the  handle  should  lie  parallel  to  the  abdominal 


EXAMINATION   BY    SOUNDS    AND   BOUGIES 


589 


wall  and  in  line  with  the  fold  of  the  groin  (Fig.  602),     From  this  posi- 
tion the  handle  is  gradually  swept  to  the  center  line  (Fig.  603),  and  the 


Fig.  604. — Third  step  in  inserting  a  urethral  sound. 


Fig.  605. — Fourth  step  in  inserting  a  urethral  sound. 

instrument  is  further  introduced  with  its  point  first  hugging  the  floor 
of  the  urethra  and  then  gently  following  the  roof  of  the  canal  through 


590 


THE  URETHRA  AND  PROSTATE 


the  rest  of  its  course  into  the  bladder.  The  instrument  is  then 
pushed  onward  and  downward,  the  penis  being  drawn  over  it  until  the 
point  of  the  sound  is  deep  in  the  bulbous  urethra  (Fig.  604).  The 
handle  is  next  gradually  raised  to  a  perpendicular  and  is  then  de- 


Fig.  606. — Showing  false  passage  of  sound  from  depressing  the  handle  of  the 

instrument  too  soon. 


Fig.  607. — Showing  the  tip  of  the  sound  caught  in  the  bulb  at  the  anterior  layer 
of  the  triangular  ligament. 

pressed,  thus  permitting  the  point  of  the  instrument  to  follow  the 
fixed  curve  of  the  urethra  beneath  the  pubic  arch  (Fig.  605). 

Care  must  be  taken,  however,  not  to  raise  the  handle  of  the  instru- 
ment too  soon,  that  is  before  the  beak  has  entered  well  into  the  bulb- 


EXAMINATION  BY    SOUNDS   AND  BOUGIES 


591 


ous  urethra,  as  otherwise  its  point  will  be  made  to  lodge  against  the 
upper  part  of  the  anterior  layer  of  the  triangular  ligament  instead  of 
entering  the  membranous  portion  (Fig.  606) .     Again,  the  sound  may 


Fig.  608. — Method  of  lifting  up  the  tip  of  the  sound  obstructed  by  the  lower 
portion  of  the  triangular  ligament. 


Fig.  609. — Final  step  in  inserting  a  urethral  sound. 


fail  to  enter  the  membranous  urethra  from  the  point  lodging  in  the 
bulbous  urethra  against  the  lower  portion  of  the  triangular  ligament 
(Fig.  607).  This  may  be  avoided  by  depressing  the  handle  and  at  the 
same  time  by  lifting  up  on  the  point  of  the  instrument  with  the  fin- 


592  THE    URETHRA    AND    PROSTATE 

gers  inserted  behind  the  scrotum  so  as  to  press  against  the  perineum 
(Fig.  608). 

'  Having  passed  the  beak  of  the  sound  into  the  membranous 
urethra  it  is  then  made  to  traverse  the  remainder  of  the  canal  and  to 
enter  the  bladder  by  sweeping  the  handle  forward  and  downward 
between  the  thighs  (Fig.  609),  provided,  of  course,  that  no  obstruc- 
tion has  been  encountered.  While  this  is  being  done  the  free  hand 
should  make  pressure  over  the  pubes  in  order  to  relax  the  suspensory- 
ligament  of  the  penis. 

By  rotating  the  sound  about  its  own  axis  it  can  readily  be  ascer- 
tained whether  the  beak  has  entered  the  bladder  or  is  still  in  the 
prostatic  urethra.  Furthermore,  by  sweeping  the  beak  of  the  instru- 
ment about  the  vesical  neck  any  irregularity  or  disproportion  between 
the  two  lobes  of  the  prostate  will  be  noticed. 

If  an  obstruction  is  met  in  any  portion  of  the  canal,  the  instrument 
should  be  slightly  withdrawn,  and  the  penis  put  on  the  stretch,  so  as 
to  straighten  out  any  folds  of  mucous  membrane  in  which  the  point 
of  the  instrument  may  have  caught.  If  it  then  fails  to  pass,  the 
obstruction  is  due  either  to  spasm  or  to  an  organic  stricture.  When 
the  seat  of  obstruction  is  in  front  of  the  bulbous  urethra,  spasm  may 
be  ruled  out,  but  an  obstruction  at  the  bulbo-membranous  junction  or 
in  the  membranous  urethra,  on  the  other  hand,  is  often  caused  by 
spasm.  To  determine  this,  the  instrument  is  not  withdrawn,  but 
should  be  kept  firmly  and  gentl}'  pressed  against  the  face  of  the  ob- 
struction for  a  few  moments,  when,  if  spasm  were  the  cause,  it  will  in 
time  subside  so  that  the  instrument  can  be  readily  passed  into  the 
bladder.  Furthermore,  upon  attempting  to  withdraw  the  instru- 
ment, that  characteristic  grasping  of  the  instrument  such  as  is  found 
in  the  presence  of  a  tight  organic  stricture  will  be  absent.  When  an 
obstruction  is  met  deeper  than  6  1/2  inches  (16.5  cm.)  from  the  mea- 
tus, or  in  the  prostatic  urethra,  stricture  may  be  ruled  out;  such  an 
obstruction  may  be  due  to  an  enlarged  prostate,  a  stone,  or  spasm  of 
the  internal  sphincter. 

In  this  way  the  presence  of  a  stricture  is  determined  and  its  dis- 
tance from  the  meatus  is  readily  estimated.  To  ascertain  its  caliber 
is  the  next  thing.  When  the  examining  instrument  encounters  the 
stricture  no  force  should  be  used  in  attempting  to  make  it  pass; 
instead,  that  particular  instrument  is  withdrawn,  and  smaller  sizes 
inserted  in  succession,  substituting  flexible  bougies  for  steel  instru- 
ments below  a  No.  15  French,  until  an  instrument  is  found  that  will 
readily  pass.     If  even  the  smallest-size  bougies  will  not  pass,  filiforms 


EXAMINATION  BY    SOUNDS   AND  BOUGIES 


593; 


should  be  used.  As  a  general  rule,  no  attempt  should  he  made  to  pass 
a  filiform  on  the  same  day  that  other  exploration  has  been  attempted,  for 
after  repeated  attempts  have  been  made  to  pass  an  instrument,  the 
opening  in  the  stricture  becomes  distorted  from  pressure  of  the  sounds 
or  bougies,  and  for  a  time  is  impassable  even  to  a  filiform.  In  using 
filiforms  it  should  be  remembered  that,  owing  to  their  small  size,  they 
are  liable  to  be  obstructed  from  being  caught  in  folds  of  mucous  mem- 
brane or  in  the  orifices  of  the  glands  and  ducts  so  abundant  through- 
out the  urethra,  and  it  is  very  easy  to  make  a  false  passage  with  one  of 
these  instruments  if  undue  force  is  used.  If  a  filiform  catches  in  a 
pocket  or  fold  of  mucous  membrane,  it  should  be  withdrawn  slightly, 
and  then  gently  advanced,  or  it  may  be  gently  rotated  as  it  is  ad- 
vanced. Sometimes  the  passage  of  a  filiform  will  be  greatly  facili- 
tated by  injecting  sufficient  sterile  oil  through  the  meatus  alongside 
the  filiform  to  thoroughly  distend  the  canal,  and  then,  while  keeping 
the  lips  of  the  meatus  closed,  the  instrument  is  gently  advanced. 


Fig.  6 10. — Showing  the  method  of  passing  a  fiHform  bougie  through  a  small 
stricture  by  first  filling  the  canal  with  filiforms. 


When  once  an  instrument  has  entered  the  stricture  there  can  be  no 
doubt  of  this  fact  from  the  tightness  with  which  it  is  grasped  by  the 
stricture,  a  sensation,  which,  once  recognized,  will  not  be  forgotten. 
Should  the  operator  be  unable  to  find  the  opening  with  a  single  fili- 
form, the  canal  may  be  filled  with  them  and,  by  first  advancing  one 
and  then  another,  it  will  usually  be  possible  to  make  one  engage  in  the 
stricture  (Fig.  6io).  Failing  by  this  maneuver,  a  urethroscope  may 
38 


594  THE  URETHRA  AND  PROSTATE 

be  introduced  down  to  the  face  of  the  stricture  and  through  it  the 
instrument  may  be  passed  under  direct  vision. 

After  such  exploration  the  urethra  should  be  irrigated  with  warm 
normal  salt  solution  or  with  a  warm  saturated  solution  of  boric  acid. 

EXAMINATION  BY  THE  BOUGIE  A  BOULE 

The  bougie  a  boule  or  bulbous  bougie  is  employed  for  the  purpose 
of  determining  the  size  and  length  of  a  stricture.  The  usefulness  of 
this  instrument  is  limited  to  the  anterior  urethra,  as,  if  passed  into  the 
membranous  portion,  the  compressor  urethrae  muscle  is  liable  to  con- 
tract about  the  bulb  of  the  instrument  and  give  a  sensation  of  stric- 
ture. Furthermore,  when  the  canal  is  the  seat  of  more  than  one 
stricture,  it  is  frequently  impossible  with  the  bougie  a  boule  to  detect 
the  deeper  ones,  as  those  in  the  anterior  portion  of  the  canal  may  be 
so  tight  that  the  passage  of  an  instrument  sufficiently  large  to  detect 
the  deeper  ones  is  out  of  the  question. 

Instruments. — The  bulbous  bougie  consists  of  a  flexible  shaft, 
upon  the  end  of  which  is  mounted  an  acorn-shaped  tip.  The  head  of 
the  instrument  should  be  short  and  should  join  the  shaft  at  rather  an 
abrupt  angle.  They  are  made  of  metal  or  of  woven  material  with  a 
rubber  head  (Fig.  6ii).  The  latter  are  preferable  as  being  less  rigid. 
These  instruments  are  made  in  sizes  from  5  to  40. 


O 


O 


Fig.  611. — Urethral  bougies  a  boule. 

Asepsis. — The  proper  sterilization  of  these  instruments  has  already 
been  described  in  detail  (page  587) .  The  hands  of  the  operator  are  to 
be  thoroughly  cleaned.  The  glans  penis  should  be  washed  off  with 
soap  and  water,  and  then  wiped  with  a  swab  wet  with  a  i  to  5000 
bichlorid  of  mercury  solution  followed  by  sterile  water.  The  urethra 
should  be  irrigated  with  a  i  to  5000  potassium  permanganate  solu- 
tion, or  a  saturated  solution  of  boric  acid  both  before  and  after 
examination. 

Position  of  Patient. — The  patient  lies  upon  a  firm  table  in  the 
dorsal  position.  The  operator  stands  upon  the  side  most  convenient 
for  him,  facing  the  patient's  body  and  just  above  his  hips. 


EXAMINATION  BY   THE  BOUGIE   A  BOULE 


595 


Technic— As  large  an  instrument  as  will  pass  the  meatus  is  chosen. 
The  operator  grasps  the  penis  behind  the  corona  between  the  middle 


Fig.  6 12. — Method  of  estimating  the  length  of  a  urethral  stricture.     The  bougie  4 
boule  arrested  at  the  face  of  the  stricture. 


Fig.  613. — ^Method  of  estimating  the  length  of  a  urethral  stricture.  The 
base  of  the  bougie  a  boule  withdrawn  until  in  contact  with  the  distal  end  of  the 
stricture. 

and  ring  fingers  of  the  left  hand,  and  with  the  thumb  and  forefinger  of 
the  same  hand  retracts  the  foreskin  and  opens  the  meatus.     The 


396  THE  URETHRA  AND  PROSTATE 

bougie,  well  lubricated  and  held  lightly  between  the  thumb  and  first 
two  fingers  of  the  right  hand,  is  introduced  until  an  obstruction  is 
met  (Fig.  612).  The  distance  of  the  obstruction  from  the  meatus  is  . 
measured  upon  the  shaft  and  the  instrument  is  withdrawn.  Success- 
ively smaller  sizes  are  introduced  until  a  size  that  will  pass  the  stric- 
ture is  reached.  From  this  the  size  of  the  stricture  is  determined. 
The  instrument  is  passed  entirely  through  the  stricture,  and  is  then 
withdrawn  until  resistance  caused  by  the  shoulder  of  the  instrument 
striking  the  distal  face  of  the  stricture  is  felt  (Fig.  613).  The  shaft  is 
then  grasped  at  the  meatus  as  a  guide,  and  the  instrument  is  removed. 
The  distance  from  the  meatus  to  the  shoulder  is  then  measured,  and 
subtracting  the  previous  measurement  from  this  gives  the  length  of 
the  stricture.  In  this  way  the  entire  anterior  urethra  to  the  bulbo- 
membranous  junction  may  be  explored  and  strictures,  if  present, 
calibrated. 

In  exploring  the  deep  urethra  the  shaft  of  the  instrument,  if  of 
wire,  should  be  bent  to  correspond  to  the  normal  curve  of  the  canal. 
It  is  then  introduced  in  the  same  manner  as  a  sound  (see  page  587). 
As  already  mentioned,  spasmodic  contraction  of  the  compressor 
urethrae  muscle  may  simulate  stricture.  After  removal  of  the  bou- 
gie the  urethra  should  be  irrigated  with  boric  acid  solution. 

URETHROMETRY 

It  is  a  method  of  measuring  the  caliber  of  the  anterior  urethra  by 
means  of  a  special  instrument,  the  urethrometer.  This  instrument 
has  an  advantage  over  a  sound  or  bougie  in  that  it  can  be  introduced 
through  a  narrow  meatus  and  strictures  of  large  caliber  can  be  de- 
tected and  measured.  At  the  same  time,  several  strictures  may  be 
examined  by  one  insertion  of  the  instrument.  The  method  is,  how- 
ever, more  irritating  to  the  urethral  mucous  membrane  than  the  use 
of  a  sound  or  bougie,  and  it  is  only  applicable  to  the  anterior  urethra. 
In  inexperienced  hands  it  is  often  an  unreliable  method  of  examina- 
tion, as  strictures  that  do  not  exist  may  be  imagined  to  be  present, 
which  turn  out  to  be  the  normal  constrictions  of  the  canal. 

Instruments. — The  urethrometer  of  Otis  (Fig.  614)  consists  of  a 
small  straight  cannula  marked  oft'  in  inches  and  half-inches,  ending  in 
a  series  of  short  metallic  arms  hinged  upon  themselves,  and  upon  the 
shaft  of  the  instrument,  which  may  be  enlarged  into  a  bulb-like  shape 
of  any  size — from  16  to  45  French — by  turning  a  thumb-screw  at  the 
proximal  end  of  the  instrument.     A  dial  and  indicator  show  the 


ESTIMATION  OF  THE  LENGTH  OF  THE  URETHRA       597 

extent  of  expansion.  A  thin  rubber  stall  is  drawn  over  the  end  of 
the  instrument  when  closed,  for  the  purpose  of  protecting  the  urethra. 

Asepsis. — The  urethrometer  is  boiled  in  a  i  per  cent,  solution  of 
carbonate  of  soda.  The  external  genitals  are  thoroughly  cleansed, 
and  the  urethra  is  irrigated  with  a  mild  antiseptic  solution.  The 
operator's  hands  are  sterilized  in  the  usual  way. 

Position  of  Patient. — The  patient  is  placed  in  the  dorsal  recum- 
bent posture. 


Fig.  614. — Otis'  urethrometer.      a,    Instrument    open;  h,    instrument    closed;  c, 
rubber  stall  to  cover  the  end  of  instrument. 

Technic. — The  closed  instrument,  warmed  and  lubricated,  is 
introduced  through  the  meatus  and  is  passed  as  far  as  the  bulbo- 
membranous  junction.  The  bulb  is  then  expanded  by  turning  the 
thumbscrew  upon  the  proximal  end  of  the  instrument  until  the  pa- 
tient feels  a  fulness  in  the  perineum.  This  indicates  the  normal  size 
of  that  portion  of  the  urethra.  The  instrument  is  then  slowly  with- 
drawn until  an  obstruction  is  met,  when  the  instrument  is  screwed 
down  until  it  is  of  sufhciently  small  size  to  pass  and  is  then  again  en- 
larged and  drawn  forward.  In  this  way  the  entire  anterior  urethra 
may  be  measured,  and  strictures  located  and  calibrated.  It  should 
be  remembered  when  employing  this  instrument  that  the  urethra  is 
not  of  uniform  caliber,  but  normally  is  the  seat  of  dilatations  and 
constrictions.  Thus,  the  bulbous  urethra  is  the  widest  and  most 
distensible  portion,  and  the  meatus  the  most  contracted.  More  or 
less  constriction  of  the  canal  is  also  encountered  at  the  peno-scrotal 
junction. 

At  the  completion  of  the  operation  the  canal  is  irrigated  with  an 
antiseptic  solution. 

ESTIMATION  OF  THE  LENGTH  OF  THE  URETHRA 

This  procedure  is  of  value  in  determining  whether  the  prostate  is 
enlarged.  For  practical  purposes  the  length  of  the  urethra  is  the 
distance  it  is  necessary  to  pass  a  catheter  from  the  meatus  before 
urine  begins  to  flow.     This  may  vary  from  6  1/2  to  9  inches  (16  to  22 


598  THE  URETHRA  AND  PROSTATE 

cm.),  but  on  the  average  it  is  7  1/2  to  8  1/4  inches  (19  to  21  cm.).  A 
marked  increase  beyond  the  normal  in  the  urethral  length  indicates 
that  the  prostatic  urethra  is  lengthened  and  that  the  prostate  is 
therefore  enlarged. 

Instruments. — An  ordinary  silk  gum-elastic  catheter  or  a  catheter 
marked  off  in  inches  (Fig.  615)  may  be  employed. 

Asepsis. — The  catheter  is  boiled  or  immersed  in  a  i  to  20  carbolic 
acid  solution  followed  by  rinsing  in  sterile  water.     The  external 


Fig.  615. — Catheter  marked  off  in  inches. 

genitals  are  thoroughly  cleansed  and  the  urethra  is  irrigated  with  a 
mild  antiseptic  solution.  The  operator's  hands  are  also  thoroughly 
cleansed. 

Position  of  Patient. — The  dorsal  position  is  employed. 

Technic. — The  catheter,  well  lubricated,  is  introduced  into  the 
bladder  until  urine  begins  to  flow.  It  is  then  withdrawn  until  the 
flow  just  stops  and  the  point  where  the  catheter  protrudes  from  the 
meatus  is  noted.  The  distance  from  this  mark  to  the  eye  of  the 
catheter  represents  the  length  of  the  urethra.  If  the  catheter  passes 
without  obstruction  and  urine  begins  to  flow  when  the  eye  of  the 
catheter  is  a  distance  of  from  7  1/2  to  8  1/4  inches  (19  to  21  cm.)  from 
the  meatus,  we  may  conclude  that  the  prostate  is  not  enlarged.  On 
the  other  hand,  a  marked  increase  in  the  distance  the  catheter  has  to 
travel  indicates  an  increase  in  the  length  of  the  prostatic  urethra. 

URETHROSCOPY 

It  consists  in  direct  inspection  of  the  interior  of  the  urethra  through 
a  metal  tube  by  the  aid  of  suitable  illumination.  While  in  the  routine 
examination  of  the  urethra  direct  inspection  is  not  always  necessary, 
the  urethroscope  becomes  a  valuable  instrument  for  the  diagnosis  of 
conditions  in  which  the  pathological  changes  are  slight  and  of  such  a 
character  as  not  to  be  detected  by  means  of  the  sound  or  bougie. 
Lesions  of  the  mucous  membrane  may  be  thus  accurately  located  and 
their  character  definitely  determined.  Furthermore,  by  means  of  the 
urethroscope,  it  is  possible  to  make  local  applications  directly  to  dis- 
eased areas  or  to  remove  calculi,  foreign  bodies,  pol}-pi,  etc.  (see  page 
620).  The  instrument  is  also  sometimes  of  value  in  the  treatment 
of  strictures,  as  by  its  aid  it  is  possible  to  discover  the  opening  of  a 


URETHROSCOPY 


599 


very  tight  or  eccentrically  placed  stricture  and  insert  a  filiform  under 
direct  vision. 

To  successfully  employ  the  urethroscope  care  and  gentleness  in 
manipulation  are  absolutely  essential  and  the  operator  must  have  had 
considerable  experience  in  its  use  and  must  be  familiar  with  the 
normal  appearance  of  the  different  portions  of  the  urethra  in  order  to 
properly  interpret  the  findings.  If  strictures  exist  or  the  caHber  of 
the  canal  is  below  22  French,  preliminary  dilatation  by  means  of 
sounds  should  be  carried  out.  In  acute  gonorrhea  the  use  of  the 
urethroscope  is  contraindicated. 


Fig.  616. — Instruments  for  urethroscopy,      i,  Chetwood's  tubes;  2,  tube  with  light 

in  place;  3,  applicator. 


Apparatus. — The  urethroscope  consists  of  a  metal  tube  supplied 
with  an  obturator  to  aid  in  its  introduction  and  an  electric  light  for 
illuminating  its  interior.  The  tubes  for  use  in  the  anterior  ure- 
thra are  straight  and  are  4  to  5  inches  (10  to  12  cm.)  long,  while  those 
for  the  posterior  urethra  are  5  to  6  inches  (12  to  15  cm.)  long;  a 
straight  tube  may  be  used  in  the  posterior  urethra  or  the  tube  may 
be  obtained  with  the  distal  end  slightly  curved  to  facilitate  its  intro- 
duction, as  the  Swinburne  urethroscope  (Fig.  617)  or  the  Goldschmidt 
instrument.  The  caliber  of  the  tubes  is  from  22  to  32  French.  The 
illumination  is  furnished  through  a  two-  or  four-volt  lamp  from  a 
four-  to  six-dry-cell  battery.     In  the    Chetwood   instrument,   the 


6oo 


THE    URETHRA    AXD    PROSTATE 


illumination  is  supplied  by  means  of  a  delicate  cold  lamp  at  the 
distal  end  of  the  instrument,  while  in  the  Otis  urethroscope  the 
light  is  placed  at  the  proximal  end  of  the  instrument.  In  their 
stead,  a  head  light  and  Klotz  tube  (Fig.  6i8)  may  be  employed. 

In  addition  to  the  urethroscope  long  slender  applicators  wrapped 
with  cotton  are  necessary. 


Fig.  617. — Swinburne's  urethroscope  for  e.xamining  the  posterior  urethra 


Asepsis. — The  tube  and  applicators  should  be  boiled  for  five 
minutes  in  a  i  per  cent,  soda  solution,  while  the  lamp  may  be  im- 
mersed in  a  I  to  20  carbolic  acid  solution  and  then  in  alcohol.  The 
operator's  hands  should,  of  course,  be  sterile.  The  glans  penis  is 
washed  with  soap  and  water,  and  is  then  wiped  with  a  i  to  5000 
bichlorid  of  mercury  solution.  The  urethra  is  to  be  irrigated  with 
a  warm  saturated  solution  of  boric  acid  or  i  to  5000  potassium 
permanganate  solution. 

Position  of  Patient. — The  patient  should  be  upon  a  flat  table  in 
the  recumbent  position  for  anterior  urethroscopy  and  in  the 
lithotomy  position  for  examination  of  the  posterior  urethra. 


Fig.  618. — Klotz's  urethral  tube. 


Anesthesia. — Cocain  is  not  to  be  used  if  it  can  be  avoided,  as  it 
alters  the  appearance  of  the  mucous  membrane  somewhat  and  by 
deadening  sensibility  it  conceals  valuable  information  as  to  the  con- 
dition of  the  canal.  Hyperesthesia  of  the  urethra,  if  present,  may  be 
lessened  to  a  considerable  degree  by  the  passage  of  a  full-sized  sound 
once  or  twice  before  the  intended  examination  by  the  urethroscope. 

Technic. — A  tube  as  large  as  will  pass  through  the  meatus  should 
be  used,  as  very  little  information  is  obtained  by  inspection  through 


URETHROSCOPY 


6oi 


a  small  tube.  If  the  meatus  is  abnormally  small,  it  should  be  cut 
(see  page  626).  The  patient  voids  his  urine  naturally  just  before 
the  examination  is  begun.  Before  proceeding  with  the  examination, 
the  patient  is  instructed  to  tell  the  operator  if  any  particular  sensi- 
tive spot  is  encountered  while  the  instrument  is  being  passed.  The 
penis  is  held  vertically  upward  in  the  fingers  of  the  left  hand,  and 
the  tube,  well  warmed  and  lubricated,  and  with  the  obturator  in 
place,  is  inserted  through  the  meatus  (Fig.  619),  and  thence  onward 
until  it  meets  an  obstruction  or  reaches  the  bulbous  urethra,  pro- 
vided the  anterior  portion  of  the  canal  only  is  to  be  examined. 


Fig.  619. — Method  of  inserting  the  urethroscope. 

If  the  prostatic  urethra  is  to  be  inspected,  the  tube  is  inserted  all 
the  way  into  the  bladder.  This  is  accomplished  by  turning  the 
instrument  down  between  the  thighs  to  an  almost  horizontal  posi- 
tion as  soon  as  its  point  reaches  the  bulbous  urethra  and,  at  the 
same  time,  making  gentle  upward  pressure  upon  the  point  of  the 
instrument  by  means  of  the  fingers  on  the  perineum.  In  this  way 
the  point  of  the  instrument  is  made  to  pass  through  the  opening 
in  the  triangular  ligament.  The  tube  is  then  gently  pushed  on  into 
the  bladder.  Inserting  a  straight  tube  into  the  posterior  urethra  is 
generally  painful  and  it  may  not  be  possible  without  employing 
local  anesthesia;  introduction  of  the  curved  urethroscope  is  much 
less  disagreeable  for  the  patient. 

As  soon  as  the  instrument  is  inserted  to  the  desired  depth,  the 
obturator  is  removed,  the  light  is  turned  on,  and,  as  the  tube  is 


6o2 


THE   URETHRA   AND   PROSTATE 


slowly  withdrawn,  the  diflferent  portions  of  the  mucous  membrane 
are  inspected  as  they  appear  in  the  end  of  the  urethroscope  (Fig. 
620).  If  a  clear  view  of  the  mucous  membrane  is  interfered  with 
by  blood  or  secretion  collecting  in  the  end  of  the  tube,  long  appli- 
cators covered  with  cotton  should  be  inserted  through  the  instru- 
ment and  the  mucous  membrane  mopped  dry;  care  should  be  taken 
not  to  push  the  tube  back  in  the  canal  after  the  examination  has 
once  begun  without  inserting  the  obturator,  as  the  edges  of  the  tube 
might  cause  damage  to  the  parts. 


Fig.  620. — Showing  the  method  of  examining  the  anterior  urethra  through  the 

urethroscope. 


Before  one  can  become  competent  in  recognizing  pathological 
conditions  it  is  necessary  that  the  exam.iner  should  be  acquainted 
with  the  normal  appearance  and  color  of  the  urethral  mucous  mem- 
brane. Beginning  at  the  posterior  urethra  in  a  normal  case  the 
central  figure  appears  as  a  cone,  the  mucous  membrane,  which  is 
of  a  dark  red  color,  being  thrown  into  longitudinal  folds.  As  the 
instrument  is  withdrawn,  the  verumontanum  comes  to  view  in  the 
form  of  a  semilunar  curve  with  the  convexity  upward  (Fig.  621) 
and  the  mucous  membrane  appears  of  a  bright  red  color.     By  slightly 


URETHROSCOPY 


603 


changing  the  position  of  the  instrument,  it  is  possible  to  obtain  a 
view  of  the  sinus  pocularis  and  openings  of  the  ejaculatory  ducts 
(Fig.  622).  Upon  the  further  withdrawal  of  the  instrument,  the 
ridge  of  the  verumontanum  becomes  gradually  less  marked  and  the 


Fig.  621. — The  appearance  of  the 
upper  portion  of  the  prostatic  urethra. 
(After  Stern.) 


Fig.  622. — The  appearance  of.  the 
middle  portion  of  the  prostatic  urethra. 
(After  Stern.) 


mucous  membrane  takes  on  a  paler  hue.  In  the  membranous 
urethra  the  central  figure  appears  as  a  cone  with  a  central  dot, 
the  mucous  membrane  extending  out  in  radiating  folds  (Fig.  623). 
In  the  bulbous  urethra  the  central  figure  changes  to  a  vertical  slit 
with  the  mucous  membrane  bulging  on  each  side  (Fig.  624).     In 


Fig.  623. — The  appearance  of  the        Fig.  624. — The  appearance  of  the 
membranous  urethra.      (After  Stern.)       bulbous  urethra.     (After  Stern.) 

this  portion  of  the  canal  the  mucous  membrane  is  still  paler  in  color. 
The  central  figure  then  gradually  changes  from  a  vertical  slit  to  a 
triangular  opening  (Fig.  625),  and  at  the  penoscrotal  junction  it 
takes  the  form  of  a  transverse  slit  with  radiating  folds  extending  to 


6o4 


THE  URETHRA  AND  PROSTATE 


the  periphery  (Fig.  626),  In  the  pendulous  urethra  the  central 
figure  again  becomes  cone-shaped  (Fig.  627)  and,  finally,  at  the 
meatus  it  appears  as  a  vertical  slit,  the  color  of  the  mucous  membrane 
changing  from  a  pale  pink  to  a  purplish  hue. 


Fig.  625. — The  appearance  of  the  FiG.   626. — The  appearance   of  the 

perineal  portion  of  the  spongy  urethra.         urethra    at    the  penoscrotal  junction. 
(After  Stern.)  (After  Stern.) 

In  examining  the  urethra  through  the  urethroscope  it  should  be 
first  ascertained  whether  the  normal  elasticity  of  the  canal  is  im- 
paired or  not.  This  is  accomplished  by  noting  the  central  figure  as 
the  tube  is  withdrawn.  In  chronic  inflammatory  conditions  the 
urethra  becomes  more  or  less  rigid  and  does  not  immediately  collapse 


Fig.  627. — The  appearance  of  the  pendulous  urethra.     (After  Stern.) 


over  the  end  of  the  urethroscope  as  it  is  withdrawn;  instead,  the  cone- 
like central  figure  often  becomes  elongated  or  else  distorted  from 
being  contracted  at  certain  points,  if  the  inflammation  is  a  localized 
one,  and,  in  addition,  the  whole  mucous  membrane  in  such  cases 


URETHROSCOPY    IN    THE    FEMALE 


60; 


not  infrequently  becomes  of  a  paler  hue  than  normal.  Changes  in 
the  appearance  of  the  mucous  membrane  should  also  be  noted.  In 
chronic  urethritis  there  will  at  times  be  found  localized  congested 
areas,  granular  patches  which  frequently  bleed,  and  superficial 
ulcerations  covered  with  secretion.  Inflamed  lacuna  appear  as  red 
openings  upon  the  surface  of  the  mucous  membrane  from  which  will 
frequently  be  seen  exuding  drops  of  pus.  Retention  cysts,  polypi, 
etc.,  are  readily  diagnosed  by  this  means.  If,  during  the  examina- 
tion, it  is  desired  to  more  closely  study  the  condition  of  the  mucous 
membrane  at  any  particular  spot  this  may  be  accomplished  by 
pushing  that  part  into  the  field  by  digital  compression  upon  the 
urethra  below  the  end  of  the  urethroscope. 

After  removal  of  the  tube  the  anterior  urethra  should  be  irri- 
gated with  a  warm  saturated  boric  acid  or  normal  salt  solution,  and, 
if  the  instrument  has  been  passed  into  the  deep  urethra,  the  bladder 
should  also  be  irrigated. 


URETHROSCOPY  IN  THE  FEMALE 

The  female  urethra  being  shorter  and  capable  of  greater  dis- 
tention than  that  of  the  male  lends  itself  more  readily  to  examination 
by  the  urethroscope. 


Fig.  628. — Kelly's  urethral  tube-speculum. 

Instruments. — Short  male  endoscopic  tubes  or  a  regular  female 
urethroscope  may  be  employed.  They  may  be  obtained  with  the 
light  at  the  distal  end  or,  as  in  the  Kelly  tubes  (Fig.  628),  with  the 
light  reflected  from  a  head  mirror.     The  female  urethroscope  should 


6o6 


THE   URETHRA   AND   PROSTATE 


be  about  3  inches  (7.5  cm.)  long.     The  tubes  vary  in  size  anywhere 
from  24  to  36  French. 

A  Kelly  cone-shaped  urethral  dilator  (Fig.  629)  should  be  pro- 
vided for  dilating  the  meatus.  AppHcators  or  alligator-jawed  forceps 
and  absorbent  cotton  will  also  be  required. 


Fig.  629. — Kelly's  cone-shaped  urethral  dilator.      (Ashton.) 

Asepsis. — The  tubes,  applicators,  etc.,  may  be  boiled  for  five 
minutes  in  a  i  per  cent,  soda  solution.  The  lamp  is  sterilized  by 
immersion  in  a  i  to  20  carbolic  acid  solution  and  then  rinsed  off  in 
alcohol.  The  vulva  and  the  external  urethral  orifice  are  sterilized 
by  washing  with  tincture  of  green  soap  and  water,  next  with  a  i  to 
5000  bichlorid  of  mercury  solution,  and  finally  with  sterile  water. 

Position  of  Patient. — The  dorsal  posture  is  employed. 


Fig.  630. — Showing  the  method  of  dilating  the  urethra.     (Ashton.) 

Anesthesia. — If  the  urethra  is  hyperesthetic,  a  small  pledget  of 
cotton  saturated  with  a  2  per  cent,  solution  of  cocain  is  placed  in 
the  mouth  of  the  urethra  for  a  short  time  before  the  operation. 

Technic. — The  urine  is  voided  naturally  before  the  examination 
begins.  If  necessary,  the  meatus  is  dilated  sufficiently  to  admit  a 
good-sized  tube  by  means  of  a  Kelly  dilator  (Fig.  630).     The  in- 


HAND   IXJECTIOXS   FOR   THE    L^RETHBA 


607 


strument,  with  the  obturator  in  place  and  well  lubricated,  is  then 
inserted  into  the  mouth  of  the  urethra  and  is  carefully  passed  into 
the  bladder  (Fig.  631).  The  obturator  is  next  removed  and  the 
lighting  apparatus  is  properly  adjusted.  The  instrument  is  then 
gradually  withdrawn  while  the  examiner  notes  the  condition  of  the 
mucous  membrane  as  it  falls  over  the  end  of  the  tube  (Fig.  632). 

At  the  internal  urethral  orifice  there  appears  through  the  urethro- 
scope a  large  opening  surrounded  by  a  narrow  ring  of  mucous  mem- 
brane. As  the  instrument  is  withdrawn  the  central  figure  becomes 
first  more  oval  and  then  lower  do"\^TL  appears  as  a  transverse  slit  with 
the  mucous  membrane  thro-mi  into  folds  that  radiate  to  the  peri- 
phery. Finally,  at  the  external  orifice  the  central  figure  appears 
as  a  vertical  sht,  while  the  mucous  membrane  appears  throwm  into 
a  number  of  radiating  folds.     A  posterior  fold  is  especially  marked 


Fig.  631. — Introduction  of  the  urethroscope 
into  the  female  urethra.      (Ashton.) 


Fig.  632. — Showing  the  method 
of  inspecting  the  female  urethra 
through  the  urethroscope.  (Ashton.) 


in  the  upper  portion  of  the  canal;  it  is  a  continuation  of  the  trigone. 
The  points  to  be  noted  in  the  examination  have  been  sufficiently 
dealt  with  under  the  technic  of  male  urethroscopy  and  will  not  be 
repeated  here. 

Therapeutic  Measures 


HAND  INJECTIONS  FOR  THE  URETHRA. 

The  injection  of  solutions  into  the  anterior  urethra  by  means  of  a 
small  hand  syringe  is  employed  either  for  simple  cleansing  purposes 


6o8  THE  URETHRA  AND  PROSTATE 

in  preparation  lor  the  passage  of  urethral  instruments  or  for  the 
purpose  of  treating  anterior  urethritis.  The  efficiency  of  injections 
in  limiting  acute  gonorrhea  is  a  question  and  it  is  doubtful  if  they 
have  much  efifect  outside  of  removing  the  irritating  discharges  and 
cleansing  the  mucous  membrane.  They  may,  however,  be  pre- 
scribed in  the  acute  stages  in  the  form  of  mild  antiseptic  solutions 
to  be  used  by  the  patient  himself  as  an  adjunct  to  irrigations  carried 
out  by  the  physician.  In  the  declining  stages  of  the  disease  or  when 
the  condition  becomes  chronic,  astringent  injections  are  of  un- 
doubted value  in  reducing  the  congestion  and  thus  drying  up  the 
thin  discharge  that  remains. 

When  injections  are  employed,  certain  precautions  should  be 
observed.  In  the  first  place,  mild  solutions  are  preferable  to  very 
strong  ones,  as  being  less  irritating  to  the  mucous  membrane. 
They  should  not  be  strong  enough  to  cause  more  than  temporary 
pain  or  stinging,  otherwise  they  are  likely  to  do  more  harm  than 
good.  In  the  second  place,  the  greatest  gentleness  in  making  the 
injection  is  necessary  to  avoid  injuring  the  urethral  mucous  mem- 
brane. Furthermore,  whUe  it  is  desirable  that  the  solution  should 
be  brought  into  contact  with  all  the  folds  and  depressions  of  the 
mucous  membrane,  it  is  important  that  the  fluid  should  not  be  in- 
jected into  the  bladder,  which,  however,  rarely  happens,  as  the 
cut-oli"  muscle  interposes  a  barrier.  If  it  should  occur,  infective 
material  will  necessarily  be  carried  back  into  the  deep  urethra  with 
a  good  chance  of  starting  up  a  posterior  urethritis  and  epididymitis. 
For  this  reason,  only  a  small  quantity  of  fluid  should  be  injected  at 
a  time  and  that  without  force.  Used  with  these  precautions,  in- 
jections may  be  safely  employed  by  the  patient  himself  when 
desired. 


Fig.  633. — Urethral  syringe. 

The  Syringe. — The  best  form  of  instrument  for  injections  is  a 
hand  syringe  with  a  capacity  of  about  2  1/2  drams  (10  c.c).  It 
should  be  preferably  of  glass  so  that  it  can  be  sterilized  by  boiling. 
The  nozzle  should  be  cone-shaped  (Fig.  633)  that  it  may  fit  into  the 
meatus,  and  it  should  be  seen  that  it  is  perfectly  smooth.  Before 
using,  the  syringe  should  be  tested  to  see  that  the  piston  moves 


HAND    INJECTIONS    FOR    THE    URETHRA  609 

easily  and   without   any   jerks.     A  basin   should  also  be  provided 
to  receive  the  solution  that  flows  back  from  the  urethra. 

Solutions  Employed. — Many  solutions  with  soothing,  astringent, 
or  antiseptic  properties  are  employed,  a  few  of  which  are  given : 

Sedative  Injections 

I^.  Fl.  ext.  hydrastis,  TTlxx-xxx  (i .  2-2  c.c.) 

Aquae  destil.,  §i  (30  c.c.) 

I^.  Morph.  sulph.,  gr.  viii  (0.5  gm.) 

Cocainae,  gr.  iv  (0.26  gm.) 

Mug.  acaciae,  5i  (30  c.c.) 

Aquae  destil.,  q.  s.  ad  5ii  (60  c.c.) 
Astringent  Injectiotis 

I^.  Zinci  sulphatis,  gr.  iv-viii  (0.26-0.5  gni-) 

Aquae  destil.,  §iv  (12c  c.c.) 

I^.  Zinci  sulphocarbolatis,  gr.  vi-xii  (0.4-0.8  gm.) 

Aquae  destil.,  5iv  (120  c.c.) 

I^,  Plumbi  acetatis,  gr.  iv-xii  (o.  26-0.8  gm.) 

Aquae  destil.,  5iv  (120  c.c.) 

R.  Zinci  acetatis,  gr.  i-xv  (0.065-1  gm.) 

Aquae  rosae,  5i  (30  c.c.) 
Antiseptic  Injections 

I^.  Sol.  protargol,  0.25  to  i  per  cent. 

I^.  Sol.  argyrol,  5  to  10% 

I^.  Sol.  potass,  permanganat.,  '          1-5000  to  3000 

I^.  Sol.  bichlorid  of  mercury,  1-30,000 

Temperature. — The  solution  should  be  used  at  about  the  tem- 
perature of  the  body. 

Quantity. — Only  sufl&cient  quantity  of  the  solution  to  distend 
the  anterior  urethra  should  be  injected  at  a  time.  At  first  about 
5i  (4  c.c.)  should  be  used;  later  this  may  be  increased  to  oiii  (12  c.c). 

Frequency. — The  injections  may  be  employed  three  to  six  times 
daily,  depending  upon  the  severity  of  the  case.  As  the  symptoms 
improve  they  may  be  given  less  frequently.  It  should  be  remem- 
bered, however,  that  in  some  cases  after  a  time  the  continued  use 
of  injections  may  prevent  a  discharge  from  entirely  disappearing, 
and  it  is  necessary  to  stop  them  entirely  for  a  week  or  more  before 
a  cure  is   obtained. 

Position  of  Patient. — Injections  may  be  given  with  the  patient 
lying  recumbent  or  sitting  upon  the  edge  of  a  chair. 

Preparation. — The  glans  penis  and  the  lips  of  the  meatus  should 
be  washed  off  with  a  i  to  5000  solution  of  bichlorid  of  mercury. 

Technic. — The  patient  urinates  immediately  before  the  injection 
39 


6io 


THE   URETHRA   AND   PROSTATE 


is  given  so  as  to  wash  out  as  much  of  the  discharge  as  is  possible  and 
also  that  he  may  not  have  to  urinate  soon  afterward,  thus  allowing 
the  solution  to  remain  in  contact  with  the  urethra  as  long  a  time  as 


Fig.  634. — Method  of  giving  a  urethral  injection. 


Fig.  635. — Second  step  in  injection  of  the  urethra,  holding  the  solution  in  the 

urethra. 


possible.  The  syringe  is  then  tilled  with  from  i  to  2  drams  (4  to 
8  c.c.)  of  solution,  and  any  air  is  expelled  by  depressing  the  piston 
while  the  tip  is  elevated.     The  penis  is  held  back  of  the  corona  be- 


IRRIGATIONS    OF    THE    URETHRA 


6ll 


tween  the  thumb  and  forefinger  of  the  left  hand,  while  with  the  right 
hand  the  nozzle  of  the  syringe  is  inserted  into  the  meatus,  far  enough  to 
completely  occlude  the  meatus  and  prevent  leakage,  and  the  solution 
is  gently  injected  into  the  urethra  and  immediately  allowed  to  escape. 
A  second  syringeful  of  solution  is  then  injected  into  the  urethra  until 
the  latter  is  well  distended  (Fig.  634).  The  syringe  is  then  removed 
and  the  meatus  is  held  together  for  from  three  to  five  minutes  so  as 
to  keep  the  solution  in  contact  with  the  mucous  membrane  (Fig. 
635).  The  solution  is  then  allowed  to  run  out  into  the  receptacle 
provided  for  the  purpose. 


IRRIGATIONS  OF  THE  URETHRA 

Irrigation  of  the  urethra  is  accomplished  by  flushing  out  the 
canal  with  copious  quantities  of  mild  antiseptic  solutions.  It  is  a 
method  employed  extensively  in  the  treatment  of  acute  gonorrhea. 


Fig.  636. — Valentine  irrigator  and  Chetwood's  urethral  irrigating  nozzle. 

To  be  effective  large  quantities  of  fluid  must  be  used,  and  the  urethra 
must  be  so  distended  that  the  solution  comes  in  contact  with  all 
recesses  and  folds  in  the  mucous  membrane. 

It  is  claimed  that  under  the  irrigation  method  of  treatment, 


6l2  THE  URETHRA  AND  PROSTATE 

properly  employed,  the  intensity  of  the  symptoms  is  much  lessened 
and  the  duration  of  the  attack  shortened.  On  the  other  hand, 
many  authorities  oppose  this  form  of  treatment  on  the  ground  that 
it  increases  the  dangers  of  prostatic  infection  and  that  the  virulence 
of  the  infection  is  increased.  If  gentleness  is  observed  and  the  pre- 
caution is  taken  not  to  give  the  anterior  injection  under  too  great 


Fic.  637. — Chetwood's  alternating  cut-off. 

pressure,  that  is,  not  to  force  the  solution  into  the  bladder,  as  is  so 
frequently  done,  the  danger  of  complications  is  slight.  It  is  not  a 
method  of  treatment,  however,  that  can  be  paced  in  the  hands  of 
the  patient,  but  it  should  always  be  carried  out  by  the  physician. 
Both  the  anterior  and  the  posterior  urethra  may  be  irrigated. 

Apparatus. — An  irrigating  reservoir  that  can  be  raised  or  lowered 
to  any  desired  height  at  will,  such  as  Valentine's,  a  Chetwood  two- 
way  blunt  glass  urethral  nozzle,  a  waste-pail,  and  two  pieces  of  rubber 


Fig.  638. — Syringe  and  catheter  for  irtrigating  the  posterior  urethra. 

tubing,  one  about  8  feet  (240  cm.)  long  for  connecting  the  inflow 
with  the  irrigator  and  another,  a  short  piece,  leading  from  the  out- 
flow tube  to  the  waste-pail,  are  required  for  anterior  irrigations. 
While  not  absolutely  necessary,  an  alternating  irrigating  clamp 
(Fig.  637)  is  a  convenience. 

For  irrigating  the  posterior  urethra  a  No.  12  to  18  French  soft- 
rubber  catheter  with  a  smooth  beveled  eye,  and  a  large  glass  syringe 
(Fig.  638)  should  be  provided. 


IRRIGATIONS    OF    THE    URETHRA 


613 


Solutions. — ]Mild  antiseptic  solutions  are  employed.     Those  most 
frequently  used  are: 


Permanganate  of  potash, 
Bichlorid  of  mercurv', 
Silver  nitrate, 


1-6000  to  I— 1000 
1-30,000  to  I-IO,OOC 
1-15,000  to  1-2000 


Temperature. — The  solutions  should  be  used  at  about  the  body 
temperature. 

Quantity. — About  a  quart  (i  literj  of  solution  should  be  used  in 
an  anterior  irrigation. 

For  posterior  irrigations  from  4  to  12  ounces  ^120  to  360  c.c.)  of 
solution  are  employed. 

Frequency. — Early  in  the  disease,  when  the  discharge  is  free,  two 
daily  irrigations  give  the  best  results.  Later,  one  irrigation  a  day  is 
sufficient. 

Height  of  Reservoir. — The  reservoir  should  not  be  raised  above 
4  feet  (120  cm.).  Such  an  elevation  wiU  give  all  the  necessary  dis- 
tention of  the  urethra  without  forcing  the  solution  beyond  the  an- 
terior urethra.  If  it  produces  pain,  the  pressure  should  be  lessened 
by  lowering  the  reservoir  or  partially  pinching  off  the  inflow  tube. 


Fig.   639. — -Apron  for  protecting  the  patient  during  a  urethral  irrigation. 

Position  of  Patient. — For  anterior  irrigations  the  patient  may 
stand  or  be  seated  upon  the  edge  of  a  chair,  while  for  a  posterior 
irrigation  the  patient  should  be  lying  down. 

Preparation  of  Patient. — For  protecting  the  clothes  the  patient 
may  wear  a  rubber  apron  in  which  is  provided  an  opening  for  the 
penis  (Fig.  639).  The  glans  penis  and  lips  of  the  meatus  should  be 
washed  off  with  a  i  to  5000  bichlorid  of  mercury  solution. 


6i4 


THE    URETHRA    AND    PROSTATE 


Technic. — i.  Anterior  Irrigations. — The  patient  should  empty 
his  bladder  before  each  treatment.  The  operator  holds  the  penis 
behind  the  glans  between  the  thumb  and  forefinger  of  the  left  hand 
and,  compressing  the  rubber  inflow  tube  between  the  thumb  and  in- 
dex-finger of  the  right  hand,  inserts  the  glass  nozzle  into  the  meatus. 
He  then  releases  the  inflow  tube,  at  the  same  time  closing  the  out- 
flow tube  by  means  of  his  right  little  finger.  As  soon  as  the  urethra 
is  filled  with  solution  the  inflow  tube  is  again  pinched,  at  the  same 
time  removing  the  little  finger  and  thus  opening  the  outflow  tube. 


Fig.  640. — Method  of  giving  an  anterior  urethral  irrigation. 


By  thus  alternately  opening  or  shutting  the  inflow  tube,  and  at  the 
same  time  shutting  or  opening  the  outflow,  the  urethra  is  alternately 
distended  with  solution  and  emptied  without  the  necessity  of  remov- 
ing the  nozzle.  This  alternate  filling  and  emptying  of  the  urethra 
is  much  easier  to  perform  with  the  scissor-like  clamp  of  Chetwood 
than  with  the  fingers.  It  takes  about  five  minutes  to  thus  irrigate 
the  urethra  with  i  quart  (i  Hter)  of  solution. 

2.  Posterior  Irrigations. — The  anterior  urethra  is  first  irrigated 
as  just  described.  A  No.  12  to  18  French  catheter,  well  lubricated 
with  one  of  the  Irish-moss  preparations,  is  then  inserted  into  the 
urethra  with  the  eye  upward  until  urine  just  escapes  (Fig.  641). 
After  the  bladder  is  emptied,  the  catheter  is  then  withdrawn  i 
inch  (2.5  cm.)  until  its  point  lies  in  the  prostatic  urethra  and  from 
4  to  12  ounces  (120  to  360  c.c.)  of  the  antiseptic  solution  are  gently 


IRRIGATIONS    OF    THE    URETHRA 


615 


injected  (Fig.  642).     The  posterior  urethra  is  thus  washed  backward 
toward  the  bladder.     The  catheter  is  then  removed  and  the  patient 


Fig.  641. — First  step  in  irrigating  the  posterior  urethra.     Catheter  is  inserted  into 
the  bladder  until  urine  begins  to  flow. 


Fig.  642. — Second  step  in  irrigating  the  posterior  urethra.     The  catheter  is  with- 
drawn until  its  tip  lies  in  the  deep  urethra  and  the  solution  is  then  injected. 

is  instructed  to  void  the  contents  of  his  bladder,  thus  giving  a  final 
washing  from  behind  forward  to  both  posterior  and  anterior  urethras. 


6i6 


THE    URETHRA    AND   PROSTATE 


INSTILLATIONS 

Instillations  are  employed  when  it  is  desired  to  medicate  the 
urethra  with  small  quantities  of  strong  solutions.  They  are  in- 
dicated in  chronic  gonorrhea,  but  should  not  be  used  in  acute  cases; 
they  are  specially  useful  in  chronic  posterior  urethritis.  The  ob- 
ject of  such  injections  is  to  induce  a  hyperemia  of  the  tissues;  that  is, 
to  substitute  an  acute  inflammation  in  place  of  the  chronic  one  with 
the  hope  that  it  will  be  followed  by  absorption  of  the  old  as  well  as 
the  new  products  of  inflammation  and  by  a  return  to  normal.  It 
is  a  method  that  may  be  applied  to  the  anterior  or  posterior  urethra. 
Instillations  should  not  be  employed  in  cases  where  injections  or 
irrigations  of  weak  solutions  are  followed  by  irritation,  and  they 
should  likewise  be  avoided  in  posterior  urethritis  when  the  prostate 
and  seminal  vesicles  are  the  seat  of  an  acute  inflammation.  In- 
stillations are  also  valuable  in  the  treatment  of  sexual  neurasthenia 
when  inflammatory  lesions  are  present  in  the  posterior  urethra. 

The  Syringe. — While  the  instillation  may  be  given  by  means  of  a 
flexible  catheter  and  small  syringe,  a  special  instrument,  such  as 
Keyes'  modification  of  the  Ultzmann  syringe  (Fig.   643),  will  be 


Fig.  643. — Keyes-Ultzmann  instillation  syringe. 


found  more  satisfactory.  The  latter  consists  of  a  long  curved 
nozzle  of  German  silver,  provided  with  a  central  opening,  to  the 
proximal  end  of  which  is  attached  a  large  hypodermic  syringe  with 
the  piston  graduated  in  minims. 

Asepsis. — The  syringe  should  be  sterilized  by  boiling  for  five 
minutes  in  a  i  per  cent,  solution  of  sodium  carbonate.  The  glans 
penis  and  meatus  are  then  washed  with  warm  water  and  soap, 
followed  by  a  i  to  5000  bichlorid  of  mercury  solution. 

Solutions  Employed. — In  using  irrigations  it  is  well  to  start  with 
a  weak  solution,  employing  it  till  the  urethra  becomes  tolerant,  and 
then  to  gradually  increase  the  strength.  The  solutions  most  fre- 
quently made  use  of  are: 


INSTILLATIONS 


617 


Silver  nitrate, 
Thallin  sulphate, 
Copper  sulphate, 
Argyrol, 
Protargol, 
Ichthyol, 


0.5  to  2  per  cent. 
3        to  10  per  cent, 

1  to  4  per  cent. 
10  to  20  per  cent. 
0.25  to  10  per  cent. 

2  to  10  per  cent. 


Temperature. — The  solution  should  be  given  at  about  the  tem- 
perature of  the  body — say  100°  F.  (38°  C). 

Quantity. — Ten  to  twenty  minims  (0.6  to  1.25  c.c.)  solution  are 
injected  at  a  time. 

Frequency. — Instillations  may  be  given  at  from  forty-eight-  to 
seventy- two-hour  intervals.  As  a  general  rule,  a  second  injection  is 
not  to  be  given  until  all  irritation  from  the  first  has  subsided. 


Fig.  644. — Showing  the  syringe  in  position  for  a  deep  urethral  instillation. 


Position  of  Patient. — The  patient  should  be  lying  down  upon  a 
bed  or  table. 

Technic. — i.  Posterior  Instillations. — -The  patient  should  void 
his  urine  previous  to  the  instillation,  and  the  anterior  urethra  is 
first  cleansed  by  an  injection  of  weak  antiseptic  solution.  The 
syringe,  filled  with  the  desired  amount  of  solution,  and  with  the 
nozzle  well  lubricated  with  some  nonoily  lubricant,  as  one  of  the 


6l8  THE   URETHRA   AND    PROSTATE 

Irish-moss  preparations,  is  carefully  introduced  in  the  same  manner 
as  one  would  pass  a  sound  (page  587)  until  its  point  lies  behind  the 
compressor  urethrae  muscle  in  the  membranous  urethra  (Fig.  644). 
This  will  be  at  a  distance  of  about  5  1/2  to  6  inches  (14  to  15  cm.) 
from  the  meatus  or  roughly  when  the  shaft  of  the  instrument  is  at 
an  angle  of  45  degrees  with  the  horizon.  From  5  to  20  drops  (0.3 
to  1.25  c.c.)  of  solution  are  then  slowly  injected.  Care  must  be 
taken  in  withdrawing  the  nozzle  of  the  instrument  to  avoid  having 
any  solution  drip  from  the  point  along  the  anterior  urethra.  To 
avoid  this,  the  piston  of  the  syringe  should  be  withdrawn  slightly 
before  the  nozzle  is  removed. 

Generally  there  is  considerable  burning  upon  urination  following 
a  posterior  instillation  and  at  times  there  may  be  pain  and  tenesmus 
and  some  discharge  during  the  first  twenty-four  hours.  As  a  rule, 
these  symptoms  subside  within  six  to  twenty-four  hours.  If  the 
reaction  is  severe,  however,  the  patient  should  remain  quietly  in  bed 
and  an  opium  suppository  should  be  introduced  into  the  rectum  and 
heat  applied  to  the  perineum. 

2.  Anterior  Instillations. — In  giving  an  anterior  instillation  the 
same  preparations  are  followed  as  for  a  posterior  instillation.  The 
nozzle  of  the  instrument,  well  lubricated,  is  then  carefully  intro- 
duced as  far  as  the  bulb  of  the  urethra  "and  about  20  drops  (1.25 
c.c.)  of  solution  are  injected.  The  solution  follows  the  instrument 
as  it  is  withdrawn,  medicating  the  whole  anterior  urethra.  A  piece 
of  cotton  should  be  placed  over  the  glans  and  worn  for  a  few  hours 
to  prevent  any  excess  of  solution  escaping  from  the  meatus  and 
soiling  the  patient's  clothing.  The  cotton  may  be  readily  secured 
in  place  by  means  of  a  loose-fitting  elastic  band  placed  behind  the 
corona. 

APPLICATION  OF  OINTMENTS  TO  THE  URETHRA 

Astringent  and  stimulating  ointments  are  at  times  employed  in 
the  treatment  of  chronic  urethritis  instead  of  instillations.  They 
are  considered  by  some  authorities  more  efficient  than  the  use  of 
drugs  in  solution,  as  being  more  penetrating  and  more  lasting  in 
effect. 

Instruments. — Ointments  may  be  applied  to  the  whole  urethra, 
in  which  case  an  ordinary  sound  or  a  cupped  sound  (Fig.  645)  is 
employed,  or  they  may  be  brought  into  any  particular  area  by  means 
of  Tomasoli's  or  some  other  form  of  ointment  syringe  (Fig.  646). 


APPLICATION    OF    OINTMENTS    TO    THE    URETHRA 


619 


This  latter  instrument  consists  of  a  hollow  curved  catheter-like  nozzle 
and  a  plunger  for  forcing  the  ointment  out  at  the  end. 

Formulary. — Unna's  ointment  for  use  with  sounds  consists  of: 


^. 


01.  coc£e, 
Ceree  flav., 
Argent,  nitratis, 
Bals.  peruviani, 


giii  (90  c.c.j 
3ss  (2  gm.) 
gr.  XV  (i  gm.) 
3ss  (2  c.c.)     M. 


Fig.  645. — Cupped  sound. 

The  mixture  is  melted  over  a  hot-water  bath  and  the  sound  is  then 
dipped  into  it  and  the  ointment  is  permitted  to  solidify  by  cooling. 

Finger's  Ointment  consists  of: 


I^.  Argent,  nitratis  or  cu.  sulphatis, 
01.  olivffi, 
Lanolin, 

Another  consists  of: 

I^.  Pot.  iodidi., 
lodi.  pur., 
01.  olivce, 
Lanolin, 


gr.  XV  (i  gm.) 
3iss  (5.6  c.c.) 
Biii  (90  c.c.)     M. 


3ss  (2  gm.) 
gr.  V  (0.3  gm.) 
5ss  (2  c.c.) 
51(30  c.c.)     M. 


Fig.  646. — Urethral  ointment  syringe. 

Preparations. — The  patient's  bladder  should  be  empty.  The 
glans  penis  and  meatus  are  washed  with  soap  and  water,  followed  by 
a  I  to  5000  bichlorid  of  mercury  solution. 

Technic. — When  a  sound  is  employed,  as  large  a  one  as  will 
comfortably  pass  the  meatus  is  coated  with  the  ointment,  or  if  a 
cupped  sound  is  used,  the  depressions  are  filled  with  the  ointment, 
and  it  is  passed  through  the  urethra  and  is  left  in  place  about  five 
minutes.  The  ointment  melts  and  thus  medicates  the  entire  urethral 
mucous  membrane. 


620  THE  URETHRA  AND  PROSTATE 

In  employing  a  special  ointment  carrier  the  instrument  is  partly 
filled  with  the  ointment  and,  after  being  well  lubricated,  it  is  passed 
as  far  as  the  diseased  area.  The  piston  is  then  inserted  and  is 
pushed  through  the  instrument  forcing  the  ointment  out  the  end 
into  the  urethra. 

THE  URETHROSCOPE  IN  THE  TREATMENT  OF  URETHRAL 

DISEASES 

By  means  of  the  urethroscope  or  an  open  wire  speculum  (Fig. 
647)  lesions  in  the  urethra  may  be  accurately  located  and  efforts  at 
treatment  can  be  thus  focused  on  the  exact  seat  of  the  disease. 
Endoscopic  treatment  is  thus  of  great  value  in  the  presence  of 
localized  lesions  of  the  urethra  which,  resisting  the  ordinary  methods 
of  treatment  by  irrigations,  instillations,  etc..  are  often  the  cause  of 


Fig.  647. — Open  wire  urethral  speculum. 

a  persistent  gleety  discharge.  For  example,  through  the  urethro- 
scope and  by  the  aid  of  suitable  instruments,  strong  applications 
may  be  made  to  granular  patches,  erosions,  and  ulcerations;  sup- 
purating glands  or  follicles  may  be  incised  and  small  growths  may  be 
removed  from  the  canal  under  direct  vision. 

The  technic  of  using  the  urethroscope  has  previously  been  fully 
described  (page  600)  so  that  the  application  of  the  instrument  to 
the  treatment  of  various  urethral  conditions  will  simply  be  outlined 
in  a  general  way.  As  has  been  already  emphasized  in  previous 
pages,  it  is  essential  that  one  should"  be  familiar  with  the  normal  ap- 
pearance of  the  urethra  before  attempts  to  employ  the  instrument 
for  treatment  are  made.  Furthermore,  the  greatest  gentleness  in 
manipulation  is  necessary  to  avoid  injury  to  parts  already  diseased. 

In  the  treatment  of  congested  and  granular  patches,  erosions, 
and  ulcerations,  local  applications  of  silver  nitrate  or  copper  sulphate 
may  be  made  by  means  of  cotton-wrapped  probes  through  the 
urethroscope  previously  passed  to  the  seat  of  the  disease  (Fig.  649). 
In  this  way  strong  solutions  of   these  drugs — 30  to  60  gr.  (2  to  4 


TRETHROSCOPE    IX    THE    TREATMENT    OE    URETHRAL    DISEASES    62 1 

gm.)  to  the  ounce  (30  c.c.) — which  would  be  extremely  irritating  if 
applied  to  the  whole  mucous  membrane,  may  be  applied.  If  the 
diseased  areas  are  numerous  and  extensive  the  strength  of  the  appli- 


FiG.  648. — Urethral  probe. 

cations  should  be  somewhat  weaker — say  5  to  10  gr.  (0.3  to  0.6  gm.) 
to  the  ounce  (30  c.c).     When  using  the  stronger  solutions,  care 


Fig.  649. — ^Method  of  making  applications  to  the  urethra  through  the 

urethroscope. 

should  be  taken  to  make  the  application  exactly  to  the  diseased  area 
and  not  to  leave  any  excess  of  solution  to  run  over  the  healthy  mucous 


Fig.  650. — -Urethral  knife. 

membrane.     Such  applications  should  not  be  made  too  frequently — 
not  oftener  than  once  a  week — as  usually  an  acute  urethritis,  often 


622 


THE  URETHRA  AND  PROSTATE 


accompanied  by  a  bloody  discharge,  is  set  up.     This,  as  a  rule, 
subsides  in  twenty-four  to  forty-eight  hours. 

Areas  of  induration  may  be  incised  through  the  urethroscope  by 
means  of  a  urethral  knife  (Fig.  650).  Two  or  3  drops  of  a  4  per  cent, 
solution  of  cocain  with  adrenahn  chlorid  should  be  applied  to  the 
diseased  area  by  means  of  a  cotton-wrapped  probe,  and  the  incision 
may  then  be  made  without  pain.     In  the  same  manner  abscesses 


Fig.  651. — Kollmann's  urethral  syringe. 

of  Littre's  glands  or  inflamed  follicles  may  be  opened.  A  discharg- 
ing cr^-pt  or  follicle  may  be  injected  every  few  days  with  a  few  drops 
of  a  peroxid  of  hydrogen  solution  by  means  of  Kollmann's  syringe  and 


^ 


Fig.  652. — Urethral  curet. 

cannula  (Fig.  651).  Pol}'ps  and  papillomata  may  be  removed  by  a 
urethral  curet  (Fig.  652)  or  by  caustics.  If  pedunculated,  a  wire 
snare  (Fig.  653)  or  the  galvanocautery  snare  may  be  employed.     In 


Fig.  653. — Urethral  snare. 


any  case  the  area  of  operation  should  be  first  cocainized  in  the  manner 
above  described. 

THE  DIRECT  APPLICATION  OF  COLD  TO  THE  URETHRA  BY 
THE  PSYCHROPHORE 

In  the  treatment  of  spermatorrhea  and  sexual  neurasthenia  where 
the  urethra  is  congested  or  h}peresthetic  the  direct  application  of 


DIRECT    APPLICATION    OF    COLD    TO    THE    URETHRA  623 

cold  to  the  deep  urethra  by  means  of  the  cold-water  sound  or  psy- 
chrophore  is  often  of  value.  An  ordinary  cold  sound  is  also  employed 
in  treating  such  conditions,  but  is  not  so  effective,  as  the  instrument 
soon  becomes  warm  from  contact  with  the  urethra.  With  the  psy- 
chrophore  it  is  possible  to  keep  a  continuous  cold  application  in  the 
urethra  as  long  as  is  desired. 

Apparatus. — The  psychrophore  is  a  double-current  closed  sound 
within  the  outer  sheath  of  which  are  two  canals,  one  for  the  inflow 
of  cold  water  and  the  other  for  the  outflow,  which  communicate 
near  the  terminal  end  of  the  instrument,  thus  permitting  that  portion 


Fig.  654. — Apparatus  for  applying  cold  water  to  the  urethra. 

of  the  instrument  to  be  kept  cold.  The  inflow  canal  is  connected 
with  a  rubber  tube  leading  from  a  douche  bag  or  irrigating  jar 
(Fig.  654). 

Temperature. — The  temperature  of  the  water  should  be  about 
50°  to  40°  F.  (10°  to  5°  C.)  to  start  with.  As  the  urethra  grows  more 
tolerant  the  temperature  may  be  lowered. 

Duration  of  Treatments. — The  sound  should  be  left  in  place  for 
from  five  to  ten  minutes  at  a  sitting. 

Frequency. — Treatments  may  be  given  daily  or  on  alternate 
days. 

Technic. — An  instrument  as  large  as  the  normal  caliber  of  the 
urethra  should  be  used.  It  is  well  lubricated  and  gently  inserted  in 
the  same  manner  as  a  sound  (page  587)  until  the  curved  portion  lies 


624  THE  URETHRA  AND  PROSTATE 

in  the  membranous  and  prostatic  portions  of  the  urethra.  The  tub- 
ing from  the  reservoir  is  then  connected  with  the  inflow  canal  and 
a  current  of  cold  water  is  allowed  to  pass  through  the  instrument, 
escaping  from  the  outflow  canal  into  a  basin  provided  for  the  purpose. 
In  this  way  the  hyperesthetic  urethra  is  exposed  to  the  mechanical 
effect  of  the  sound  and  the  sedative  action  of  cold. 


PROSTATIC  MASSAGE 

Massage  of  the  prostate  gland  by  means  of  the  finger  in  the 
rectum  is  frequently  employed,  and  with  good  results,  in  the  treat- 
ment of  chronic  prostatitis  in  which  the  inflammation  extends  deep 
in  the  gland  tissue.  The  object  is  to  squeeze  out  of  the  prostate 
into  the  posterior  urethra  as  much  as  possible  of  the  purulent  con- 
tents of  the  gland  and  to  cause  absorption  of  the  products  of  inflam- 
mation from  indurated  areas.  It  is  also  used  for  the  purpose  of 
emptying  the  distended  seminal  vesicles  and  hastening  resolution. 
It  should  not  be  employed  in  acute  prostatitis  or  acute  vesiculitis, 
and  care  should  be  taken  not  to  perform  the  massage  too  vigorously, 
otherwise  the  tissues  will  be  bruised  and  the  inflammation  will  be 
made  worse. 

Duration  of  Treatment. — The  massage  should  be  carried  out  for 
two  or  three  minutes  at  a  sitting. 

Frequency. — Unless  followed  by  irritation,  treatments  may  be 
given  once  every  four  or  five  days. 

Position  of  Patient. — The  operation  may  be  performed  with  the 
patient  bending  forward  over  a  chair  or  in  the  knee-chest  position. 

Technic. — If  possible,  the  patient's  bladder  should  be  full.  The 
operator  wears  a  rubber  glove  on  the  right  hand  or  a  finger  cot  on  his 
right  index-finger  and,  after  lubricating  the  index-finger  well,  intro- 
duces it  into  the  rectum  (Fig.  655),  carrying  the  finger  high  up  on  one 
side  over  the  seminal  vesicle.  Firm  but  gentle  pressure  is  then 
made  wilh  the  finger  over  the  seminal  vesicle  and  the  finger  is 
slowly  drawn  down  over  the  vesicle  toward  its  duct  and  also  over 
the  corresponding  lobe  of  the  prostate  (Fig.  656).  This  procedure 
is  then  repeated  upon  the  opposite  side,  and  finally  over  the  central 
portion  of  the  gland.  All  portions  of  the  gland  are  thus  massaged, 
but  special  attention  should  be  paid  to  those  portions  that  are 
enlarged  or  diseased. 

After  completing  the  massage  the  patient  urinates,  thus  emptying 
the  bladder  of  pus  and  debris  squeezed  out  b}'  the  massage. 


PROSTATIC   MASSAGE 


625 


Fig.  655. — Position  of  the  patient  and  method  of  introducing  the  finger  into  the 
rectum  in  prostatic  massage. 


Fig.  656. — Showing  the  method  of  massaging  the  prostate. 


40 


626  THE  URETHRA  AND  PROSTATE 

MEATOTOMY 

Meatotomy  consists  in  dividing  a  narrow  meatus.  It  may  be 
required  as  a  preliminary  to  the  passage  of  large  instruments  into 
the  urethra  or  bladder  and  in  the  presence  of  urethral  inflammation, 
when  the  size  of  the  meatus  is  such  that  free  drainage  is  interfered 
with.     If  properly  performed,  it  is  an  operation  without  danger. 

Instruments. — The  incision  is  best  made  with  an  Otis  meatome 
(Fig.  657)  or  with  an  ordinary  blunt-pointed  straight  bistoury. 

Location  of  Incision. — The  meatus  should  be  cut  exactly  in  the 
median  line  upon  the  floor  of  the  urethra. 


Fig.  657. — Otis'  meatome 

Preparations. — The  glans  penis  and  meatus  should  be  washed 
with  soap  and  water  followed  by  a  i  to  5000  solution  of  bichlorid  of 
mercury.  The  anterior  urethra  should  be  irrigated  with  a  saturated 
boric  acid  solution. 

Anesthesia. — To  render  the  operation  painless  the  line  of  pro- 
posed incision  is  infiltrated  with  a  o.i  per  cent,  solution  of  cocain 
introduced  through  the  frenum  or,  if  desired,  by  the  topical  applica- 
tion of  a  weak  cocain  solution  (see  page  71). 

Technic. — The  operator  retracts  the  foreskin  and,  steadying  the 
penis  between  the  thumb  and  forefinger  of  his  left  hand,  inserts  the 
knife,  with  the  cutting-edge  down,  into  the  urethra  for  a  distance  of 
I  1/2  inches  (4  cm.).  The  meatus  is  then  incised  exactly  in  the  mid- 
line by  drawing  the  knife  out.  To  allow  for  subsequent  contraction 
it  is  well  to  incise  the  canal  to  a  size  larger  than  is  desired  to  per- 
manently maintain  it — a  meatus  that  will  give  passage  to  a  No.  30 
F.  sound  is  sufficiently  enlarged.  If  it  is  found  upon  inserting  an 
instrument  that  the  constriction  has  not  been  entirely  cut,  any 
remaining  bands  should  be  divided. 

At  first  there  may  be  some  hemorrhage  from  the  incision,  but 
this  can  usually  be  controlled  by  inserting  a  plug  of  gauze  for  an 
inch  (2.5  cm.)  or  so  within  the  meatus.  Each  time  the  patient 
urinates  this  plug  is  removed  and  a  fresh  one  inserted.  Should  the 
bleeding  be  severe,  the  incision  should  be  grasped  between  the 
thumb  and  forefinger  placed  on  either  side  of  the  frenum  and  should 
be  comp-ressed  until  the  hemorrhage  stops. 


THE    TREATMENT    OF    STRICTURES  627 

The  After-treatment.— This  consists  in  passing  a  full-sized 
straight  sound  through  the  meatus,  at  first  daily  and  then  every 
second  day  for  a  week  or  ten  days,  otherwise  the  narrowing  is  apt 
to  reform.  When  meatotomy  is  performed  as  a  preliminary  to 
instrumental  examination,  the  exploration  may  be  performed  at 
the  same  sitting. 

THE    TREATMENT    OF    STRICTURES    BY    INSTRUMENTAL 

DILATATION 

The  methods  of  treatment  applicable  to  organic  stricture  of  the 
urethra  include  gradual  dilatation,  continuous  dilatation,  and  cut- 
ting the  stricture  either  from  within — internal  urethrotomy — or 
from  without — external  urethrotomy.  Two  other  methods,  namely, 
di\ailsion  and  electrolysis,  which  are  sometimes  described  in  text- 
books, are  now  practically  obsolete.  Divulsion  is  so  dangerous  that 
it  has  been  abandoned,  while  electrolysis  is  an  operation  that  is  of 
doubtful  benefit  and  has  never  found  much  favor. 

Intermittent  dilatation  of  strictures  by  the  passage  of  instru- 
ments of  increasing  size  should  be  the  method  of  choice  when  pos- 
sible, as,  if  properly  performed,  it  is  without  danger.  It  is,  of  course, 
only  applicable  to  strictures  which  are  permeable,  but  a  large  pro- 
portion of  such  may  be  successfully  treated  by  this  method.  It  is 
especially  suited  to  those  strictures  which  are  fairly  recent,  soft,  and 
dilatable.  For  old  strictures  with  considerable  scar  tissue  format- 
tion,  which  are  rigid  and  unyielding,  attempts  at  dilatation  are 
apt  to  fail,  so,  if  after  a  fair  trial  of  the.  method  in  these  cases  it 
does  not  give  results,  more  radical  means  of  treatment  should  be 
substituted.  Again,  intermittent  dilatation  is  not  apt  to  be  suc- 
cessful when  applied  to  the  so-called  resilient  strictures;  these,  while 
dilatable,  are  so  elastic  that  they  recontract  between  treatments, 
and  little,  if  any,  advance  is  made  beyond  a  certain  point.  Stric- 
tures which  are  irritable,  that  is,  those  in  which  attempts  at  dilata- 
tion are  followed  by  pain  and  spasm  resulting  in  retention  of  urine, 
those  in  which  the  passage  of  instruments  is  followed  by  chills  and 
fever,  those  complicated  by  numerous  false  passages  and  suppurating 
fistulous  tracts,  and  all  strictures  near  the  meatus  should  be  cut. 
For  strictures  complicated  by  cystitis,  intermittent  dilatation  is 
Kkewise  undesirable  on  account  of  the  dangers  of  pyelonephritis; 
these  require  cutting  of  the  stricture  and  free  drainage  of  the  bladder. 

Before  making  any  attempt  to  treat  strictures,  the  number  of 


628  THE   URETHRA   AND   PROSTATE 

Strictures,  their  exact  location,  their  size,  and  their  extent  should  be 
determined  by  instrumental  exploration  of  the  urethra,  and  sufficient 
time  for  the  tissues  to  react — at  least  seventy-two  hours— should 
elapse  after  such  an  examination  before  the  dilatation  is  begun. 
Strictures  may  occur  at  any  point  in  the  canal  except  in  the  prostatic 
urethra,  but  the  most  frequent  sites  are:  (i)  in  the  region  of  the 
bulbomembranous  junction,  (2)  within  2  1/2  inches  (6  cm.)  of  the 
meatus,  and  (3)  near  the  penoscrotal  junction.  They  may  be  single 
or  multiple,  and  in  shape  annular  or  tortuous.  The  opening  is 
seldom  situated  in  the  center  of  the  stricture,  but  generally  lies  to  one 
side  of  the  median  line  of  the  urethra. 

All  strictures  have  a  tendency  to  contract  and  in  time  cause 
more  or  less  impediment  to  the  urinary  flow  with  serious  results  to  the 
whole  urinary  tract.  The  urethra  immediately  behind  the  stricture 
is  the  first  to  feel  the  effects  of  this  obstruction  and  the  canal  at  this 
point  becomes  more  or  less  dilated  and  the  mucous  membrane  is 
thinned  out.  Urine  collects  in  this  dilated  portion  and  decomposes, 
with  the  result  that  an  inflammation  is  set  up  accompanied  by  a 
gleety  discharge.  This  may  in  time  go  on  to  ulceration  and  extra- 
vasation of  urine  with  the  formation  of  false  passages  and  fistulas. 
The  effect  of  the  urinary  obstruction  is  also  felt  upon  the  bladder. 
It  first  hj-pertrophies  and  may  later  become  thinned  and  dilated, 
and  it  is  not  uncommonly  the  seat  of  cystitis.  In  time  inflammation 
and  dilatation  of  the  ureters  and  kidney  follow,  resulting  in 
pyelitis  and  pyelonephritis. 

Mention  is  made  of  these  compHcations  because  their  presence, 
or  absence,  and  severity,  af  present,  are  of  direct  practical  impor- 
tance in  determining  the  method  of  treatment  to  pursue.  It  should 
further  be  borne  in  mind  that  the  stricture  itself  is  usually  congested 
and  the  mucous  membrane  is  softened  and  inflamed,  so  that  in 
performing  dilatation  the  greatest  care  and  gentleness  are  necessary  to 
avoid  lacerating  and  contusing  the  already  irritated  tissues.  Rough- 
ness or  carelessness  in  introducing  the  instrument  can  do  only 
harm.  The  beneficial  effects  of  dilatation  depend  not  only  upon 
the  mechanical  distention  to  which  the  urethra  is  subjected,  but  also 
upon  the  simple  presence  of  the  instrument  which  stimulates  the 
tissues  to  a  mild  reactionary  hyperemia,  which  is  accompanied  by 
softening  and  absorption  of  the  scar  tissue.  If  more  than  this  is 
done,  that  is,  if  the  tissues  are  so  irritated  than  an  inflammation  is 
induced,  the  value  of  the  treatment  is  lost  and  the  original  trouble 
is  simply  aggravated. 


THE    TREATMENT    OF    STRICTURES 


629 


Instruments. — For  strictures  above  No.  15  French  conical  steel 
sounds  of  proper  curve  are  employed.  These  may  be  of  the  style 
shown  in  Fig.  658,  or  those  with  a  double  taper  (Fig.  659)  may  be 
used.  The  latter  instrument  has  a  slight  advantage  in  that,  the 
shaft  being  smaller  than  the  shoulder,  dilatation  of  the  deeper  parts 
is  effected  without  unduly  stretching  the  meatus.     For  strictures 


Fig.  658. — Conical  steel  sound. 

in  the  pendulous  urethra  in  front  of  the  bulb  a  straight  conical  sound 
(Fig.  660)  may  be  employed;  such  an  instrument  should  not  be  used, 
however,  in  the  deep  urethra. 

Kollmann  dilators  are  used  in  preferance  to  sounds  by  some 
operators.  They  are  made  on  the  principle  of  the  Otis  urethrometer 
with  four  blades  regulated  by  a  wheel  at  the  proximal  end  of  the 


Fig.  659. — Double-taper  steel  sound. 

instrument.  A  dial  and  indicator  show  the  extent  to  which  the 
blades  are  separated.  Two  styles  of  dilators  are  generally  em- 
ployed— a  straight  one  for  the  anterior  urethra  (Fig.  661)  and  a 
curved  instrument  (Fig.  662)  for  the  posterior  urethra.  Some  are 
supplied  with  attachments  for  irrigating  the  urethra.  A  rubber 
sheath  is  provided  with  these  instruments  to  be  drawn  over  the 


Fig.  660. — Straight  steel  sound. 

blades  (Fig.  663)  and  so  avoid  injuring  the  urethral  mucous  mem- 
brane when  the  instrument  is  being  closed.  This  is  not  used,  how- 
ever, with  the  irrigating  dilators.  When  closed  the  instruments 
measure  20  French  and  may  be  expanded  to  45  French.  On  account 
of  their  small  size,  they  may  be  used  for  dilating  strictures  in  the 
presence  of  a  narrow  meatus  without  first  cutting  the  latter. 


630 


THE   URETHRA   AND   PROSTATE 


With  small  steel  instruments  there  is  a  considerable  chance  of 
making  a  false  passage  and  always  the  danger  of  inflicting  traumatism, 


Fig.  661. — KoUmann's  straight  dilator. 


Fig.  662. — KoUmann's  curved  dilator 
for  the  posterior  urethra  with  irrigat- 
ing attachment. 


Fig.  663. — Rubber  sheath  in  position. 

so  that  for  strictures  of  a  smaller  size  than  No.  15  French,  soft  instru- 
ments should  be  employed.  Flexible  olivary  bougies  (Fig.  664)  are 
the  best  in  this  class  of  cases,  as  they  find  their  way  through  the 


THE    TREATMENT    OF    STRICTURES  63 1 

Stricture  with  greater  ease  and  there  is  less  danger  of  making  a  false 
passage.  They  are  made  of  woven  material  covered  with  rubber 
and  the  best  are  of  French  make. 


Fig.  664. — Flexible  urethral  bougie. 

For  dilating  tight  strictures  whalebone  filiform  bougies  and  tun- 
neled sounds  (Fig.  665)  should  be  provided.  The  filiforms  should 
be  at  least  18  inches  (45  cm.)  long  and  of  such  size  that  the  tunneled 
sounds  will  slip  easily  over  them.  Care  should  be  taken  not  to  use 
rough  or  split  filiforms.  In  fact,  any  instrument,  no  matter  what  the 
variety,  must  be  perfectly  smooth  and  sound;  imperfect  instruments 
should  be  discarded  as  unsafe. 


Fig.  665. — Gouley  tunneled  sound  and  filiform. 

Asepsis. — The  strictest  asepsis  should  be  observed  in  regard  to 
the  instruments  used.  Metal  instruments  should  be  boiled  for  five 
minutes  in  a  i  per  cent,  solution  of  sodium  carbonate.  Filiforms  and 
the  newer  gum-elastic  instruments  will  stand  moderate  boiling. 
They  may  also  be  sterilized  by  formaldehyd  vapor,  after  which  they 
should  be  well  rinsed  in  sterile  water;  or  they  can  be  immersed  first  in 
a  I  to  20  carbolic  solution  and  then  in  a  saturated  solution  of  boric 
acid. 

The  glans  and  meatus  should  be  washed  with  soap  and  water 
followed  by  a  I  to  5000  bichlorid  of  mercury  solution.  The  urethra  is 
irrigated  both  before  and  after  each  treatment  with  a  saturated  solu- 
tion of  boric  acid  or  a  i  to  5000  permanganate  of  potash  solution,  and, 
if  the  bladder  is  infected,  it  should  likewise  be  irrigated,  provided  the 
stricture  is  sufficiently  large  to  admit  a  catheter. 

The  same  regard  to  cleanliness  should  also  apply  to  the  operator's 
hands. 

Rapidity  of  Dilatation. — This  can  only  be  determined  by  a  study 
of  the  individual  case.  It  is  important,  however,  not  to  do  too  much 
dilating  at  a  time.     It  should  not  be  carried  to  a  point  where  discom- 


632  THE   URETHRA   AND   PROSTATE 

fort  or  pain  is  caused.  If  the  stretching  is  too  rapid,  it  practically 
amounts  to  divulsion  with  its  attendant  risks  of  inflammation  and 
sepsis.  Furthermore,  tearing  of  the  stricture  results  in  new  formation 
of  tissue  which  in  turn  contracts.  In  the  case  of  tight  strictures  the 
introduction  of  a  second  instrument  after  the  first  is  sufficient.  In 
other  cases  the  dilatation  may  be  carried  further,  using  three  or  four 
instruments  in  all. 

Frequency  of  Treatment. — After  the  passage  of  an  instrument  a 
reactionary  hyperemia  sets  in  and  this  should  be  given  time  to  subside 
before  instruments  are  reintroduced.  A  lapse  of  three  to  seven  days 
should,  therefore,  occur  between  treatments — on  an  average  an  inter- 
val of  about  five  days.  One  will  be  guided,  however,  partly  by  the 
amount  of  contraction  that  takes  place  between  treatments  and  also 
by  the  toleration  of  the  urethra.  Instruments  should  never  be  passed 
so  frequently  as  to  produce  irritation.  Very  contractile  strictures 
require  short  intervals  between  the  treatments,  while  for  those  that 
are  easily  dilated  and  do  not  readily  reform  longer  intervals  may  be 
allowed.  After  the  stricture  has  been  stretched  to  28  or  30  French, 
the  intervals  between  the  treatments  may  be  increased,  at  first  to  once 
a  week,  then  once  or  twice  a  month,  and  finally  to  several  times  a 
year. 

Extent  of  Dilatation. — There  is  no  fixed  rule  to  be  followed  as  to 
the  extent  to  which  a  stricture  is  to  be  dilated.  Various  scales  have 
been  devised  for  determining  the  approximate  size  of  the  urethra  from 
comparison  with  the  circumference  of  the  penis,  but  they  are  not 
accurate.  As  a  general  rule,  dilatation  of  the  stricture  to  the  size  of 
the  meatus,  provided  it  is  of  normal  caliber,  is  sufficient. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  position 
with  his  shoulders  slightly  raised  and  thighs  a  little  flexed  and  rotated 
outward.  The  operator  takes  his  place  just  above  the  patient's  hips 
and  facing  toward  the  patient's  body,  upon  whicliever  side  is  most 
convenient  for  him. 

Anesthesia. — Local  anesthesia  is  only  necessary  where  the  patient 
is  nervous  and  the  urethra  hyperesthetic,  or  upon  the  first  passage  of  a 
sound  after  urethrotomy,  as  properly  introduced  instruments  should 
ordinarily  cause  little  or  no  pain.  In  such  cases  the  urethra  is  well 
distended  with  a  0.2  per  cent,  solution  of  cocain  and  adrenalin  solu- 
tion and  the  solution  is  confined  in  the  urethra  for  fifteen  minutes  by 
holding  the  meatus  closed. 

Technic.  1.  Large  Strictures. — Under  this  heading  will  be  con- 
sidered strictures  above  15  French  in  size. 


THE    TREATMENT    OF    STRICTURES 


633 


With  Sounds. — A  sound  of  a  size  that  will  easily  pass  through  the 
stricture — determined  by  previous  exploration — is  warmed,  well 
lubricated  with  lubrichondrin  or  other  Irish  moss  preparation,  and 


Fig.  666. — First  step  in  passing  a  sound. 

is  very  gently  introduced  in  the  following  manner:  The  operator 
grasps  the  penis  behind  the  corona  between  the  ring-  and  middle 
fingers  of  the  left  hand  and  with  the  thumb  and  index-fingers  of  the 


Fig.  667. — Second  step  in  passing  a  sound. 


same  hand  he  retracts  the  foreskin  and  separates  the  lips  of  the  mea- 
tus. The  sound  is  grasped  hghtly  between  the  thumb  and  first  two 
fingers  of  the  right  hand  and  is  carefully  inserted  into  the  urethra. 


634 


THE    URETHRA   AND   PROSTATE 


At  this  stage  the  handle  of  the  instrument  should  be  parallel  to  the 
abdominal  wall  and  in  line  with  fJie  folds  of  the  groin  (Fig.  666).  As 
the  sound  is  pushed  onward  and  downward,  the  handle  of  the  instru- 
ment is  gradually  swept  to  the  center  line  (Fig.  667)  and  is  then  slowly 
raised  to  a  perpendicular  so  that  its  beak  passes  beneath  the  pubic 
arch  (Fig.  668)  into  the  membranous  urethra.  Unless  the  stricture 
be  in  the  deep  urethra,  it  is  not  necessary  to  insert  the  sound  into  the 


.--^ 


Fig.  668. — Third  step  in  passing  a  sound. 

bladder — the  instrument  should  simply  be  passed  through  the  stric- 
ture. To  insert  the  instrument  the  full  distance,  the  handle  is 
brought  forward  and  downward  between  the  thighs  (Fig.  669). 
When  the  point  of  the  sound  reaches  the  stricture,  the  utmost 
gentleness  in  manipulation  should  be  used  in  engaging  it  in  the 
stricture,  and  no  attempt  to  enforce  the  instrument  along  should  be 
made,  until  it  is  certain  that  its  point  has  entered  the  opening  in  the 
stricture.  Having  passed  the  sound  entirely  through  the  stricture, 
it  is  removed  by  a  reversal  of  these  steps  and  a  second  one  is  intro- 
duced. If  this  causes  pain  or  spasm,  it  is  immediately  withdrawn, 
and  no  immediate  further  attempt  to  dilate  is  made.  If,  however, 
the  urethra  tolerates  the  second  instrument,  a  third  one  may  be 
introduced. 


THE    TREATMENT    OF    STRICTURES 


635 


At  the  next  sitting  the  dilatation  is  begun  by  inserting  a  sound  one 
size  larger  than  the  first  instrument  used  at  the  previous  treatment, 
and  the  dilatation  is  increased  one  or  two  sizes  as  before.  In  this  way 
the  treatments  are  continued  until  the  desired  degree  of  dilatation  is 
obtained. 

The  passage  of  the  sound  will  cause  more  or  less  smarting,  but  it 
is  only  transitory.  At  times  a  few  drops  of  blood  may  follow  the 
removal  of  the  instrument.     The  next  act  of  urination  is  apt  to  be 


Fig.  669. — Fourth  step  in  passing  a  sotind 


painful,  and  not  infrequently  the  gleety  discharge  is  increased  for 
twenty-four  or  forty-eight  hours.  The  patient  should  be  warned  of 
these  symptoms  beforehand. 

With  the  Kallmann  Dilator. — The  rubber  sheath  is  drawn  over  the 
instrument.  The  dilator,  closed  and  well  lubricated,  is  then  intro- 
duced to  the  seat  of  constriction  and  dilatation  of  the  canal  is  then 
produced  to  any  desired  extent  by  turning  the  wheel  at  the  end  of  the 
instrument.  The  stretching  must  be  performed  very  gradually  and 
with  great  care,  as  these  instruments  are  so  powerful  that  severe 
trauma  may  be  caused  by  a  too  rapid  dilatation.  If  the  patient 
complains  of  pain,  or  if  an  undue  amount  of  resistance  is  felt,  the 
dilatation  should  be  stopped.  Having  effected  the  desired  amount 
of  dilatation,  the  instrument  is  left  in  place  for  several  moments 
before  it  is  closed  and  removed.  At  subsequent  treatments  the  dila- 
tation is  increased  one  or  two  numbers  each  time. 


636  THE    URETHRA    AND    PROSTATE 

2.  Small  Slrictiires. — For  small  strictures,  that  is,  below  15 
French,  soft  bougies  are  employed.  A  bougie  of  a  size  that  will  read- 
ily enter  the  stricture  is  selected.  The  penis  is  held  straight  up  and 
upon  the  stretch  in  the  fingers  of  the  left  hand  after  the  manner  de- 
scribed above,  and  the  bougie,  well  lubricated,  is  carefully  passed 
straight  down  to  the  seat  of  obstruction  (Fig.  670),  provided  the 
latter  is  in  the  anterior  urethra.     An  instrument  can  thus  be  readily 


Fig.  670. — Method  of  inserting  a  flexible  bougie  through  a  urethral  stricture. 

passed  straight  as  far  as  the  bulbomembranous  junction,  but  here  it 
is  apt  to  be  obstructed.  To  pass  this  point  and  enter  the  deep  ure- 
thra, the  bougie  should  be  introduced  bent  as  much  as  possible  to 
the  shape  of  a  curved  sound,  and,  when  the  point  reaches  the  bulb, 
slight  pressure  should  be  made  with  the  fingers  on  the  perineum  (see 
Fig.  608).  When  the  instrument  strikes  the  face  of  the  obstruction, 
gentle  attempts  are  made  to  engage  its  point  in  the  stricture.  This 
accomplished,  the  instrument  is  pushed  on  entirely  through  the 
stricture,  and  the  dilatation  is  proceeded  with  in  the  same  manner  as 
when  using  sounds.  Steel  instruments  may  be  substituted  for  the 
bougies  when  the  dilatation  has  been  carried  as  high  as  15  French. 

3.  Filiform  Strictures. — In  the  beginning  of  the  treatment  of  a 
filiform  stricture  it  often  requires  the  greatest  perseverance  and  skill 
to  enter  the  bladder,  as  frequently  the  stricture  is  of  such  small  caliber 
or  the  opening  is  so  situated  that  it  is  extremely  difl&cult  to  engage 
even  a  fine  filiform.  Once,  however,  the  filiform  is  inserted,  the  main 
difficulty  is  surmounted.  In  introducing  fihforms  the  same  method 
is  employed  as  for  straight  bougies.     The  penis,  grasped  in  the  fingers 


THE    TREATMENT    OF    STRICTURES 


637 


of  the  operator's  left  hand,  is  put  upon  the  stretch  and  the  filiform, 
•vO-ell  lubricated,  is  inserted  along  the  floor  of  the  canal.  If  the  point 
of  the  instrument  is  obstructed  by  a  fold  of  mucous  membrane  or  the 
opening  of  some  lacuna,  it  should  be  withdrawn  slightly  and  then 
slowly  reinserted.  When  the  face  of  the  stricture — the  location  of 
which  has  been  previously  determined — obstructs  the  further  advance 
of  the  filiform  the  instrument  should  be  slowly  rotated  making 
attempts  to  engage  its  point  in  the  stricture  the  while,  but  without 
using  any  force.     Sometimes  by  distending  the  canal  with  warm  oil  it 


Fig.  671. — Method  of  passing  a  filiform  bougie  through  a  stricture  by  first  filling 

the  canal  with  filiforms. 


is  possible  to  enter  the  filiform  in  the  opening  of  the  stricture.  Fail- 
ing with  one  filiform,  a  second  may  be  inserted  beside  the  first  one  and 
the  same  manipulation  is  carried  out  as  with  the  first.  If  still  un- 
successful, additional  filiforms  are  inserted  until  the  urethra  contains 
six  or  seven  of  them.  Then  gentle  attempts  are  made  to  pass  each  in 
turn,  and  usually  one  will  finally  slip  into  the  opening  (Fig.  671), 
whence  it  can  be  readily  passed  into  the  bladder.  If,  after  a  fair 
trial,  it  is  impossible  to  insert  an  instrument,  it  is  better  to  give  up  the 
attempt  for  the  time  being,  and  try  again  a  few  days  later.  Some- 
times upon  a  second  or  third  trial  the  opening  will  be  readily  located. 
Gentle  manipulation  combined  with  perseverance  will  result  in  suc- 
cess in  the  great  majority  of  cases,  but,  if  it  is  impossible  to  pass  the 
instrument  by  these  means,  a  urethroscope  may  be  introduced  as  far 
as  the  obstruction  and  the  filiform  inserted  by  direct  sight. 


6 -.8 


THE   URETHRA  AND  PROSTATE 


Having  finally  passed  a  filiform,  the  smallest  size  tunneled  sound 
should  be  inserted  over  it  as  a  guide  (Fig.  672).  If  there  has  been 
much  manipulation  in  passing  the  filiform,  the  operator's  efforts  had 
best  stop  at  this,  or,  at  the  most,  a  second  sound  is  introduced.  At 
the  next  sitting  the  filiform  is  again  inserted  and  the  dilatation  in- 
creased by  inserting  larger  instruments  over  it  as  a  guide.  After  some 
dilatation  has  been  thus  obtained,  soft  bougies  may  be  substituted 
for  the  filiforms  and  tunneled  sounds,  and  the  treatments  may  be 
carried  out  as  outlined  above. 


Fig.  672. — Method  of  passing  a  tunneled  sound  over  a  filiform. 

Accidents  and  Complications  Attending  Dilatation. — There  are 
several  troublesome  as  well  as  serious  complications  that  may  follow 
the  passage  of  urethral  instruments. 

Shock: — In  some  cases,  in  spite  of  the  utmost  gentleness  in  manipu- 
lation, the  passage  of  a  sound  produces  sufficient  shock  to  cause  the 
patient  to  faint  or  collapse.  It  is  more  likely  to  occur  in  patients 
upon  whom  an  instrument  is  passed  for  the  first  time,  especially  if 
they  are  of  a  distinctly  nervous  type  and  look  upon  the  operation 
with  fear  and  apprehension. 

Much  may  be  done  in  preventing  such  a  complication  when  the 
nervous  element  is  in  evidence  by  avoiding  pain  through  the  use  of 
local  anesthesia.  Should  fainting  occur,  the  patient's  head  is  to  be 
immediately  lowered  and  stimulants  administered  if  necessary. 

Urethral  Chill  and  Fever. — A  form  of  urinary  septicemia  spoken  of 
as  urethral  chill  and  fever  is  liable  to  follow  urethral  instrumentation. 


THE   TREATMENT   OF    STRICTURES  639 

It  may  be  the  result  of  absorption  of  toxic  elements  which  are  present 
in  the  urine,  in  the  urethra,  or  are  introduced  from  without  with  the 
instrument,  or  it  may  be  the  result  of  shock  to  the  kidneys.  The 
condition  may  be  of  a  mild  type — in  which  case  a  few  hours  after 
the  passage  of  the  instrument  the  patient  is  seized  with  a  chill  fol- 
lowed by  fever,  more  or  less  prostration,  and  within  twenty-four 
hours  recovery — or  it  may  be  severe  and  progressive  and  eventually 
result  in  the  death  of  the  patient. 

Preventive  treatment,  which  is  of  the  greatest  importance,  should 
consist  in  rigid  asepsis,  gentle  manipulation  of  urethral  instruments, 
and  antiseptic  irrigations  or  instillations  after  any  instrument  has 
been  used.  Actual  treatment  comprises  rest  in  bed,  quinin  in  5-  or  10- 
grain  (0.3  to  0.6  gm.)  doses,  and  the  administration  of  genitourinary 
antiseptics.  In  the  presence  of  urinary  suppression,  hot  baths  or 
hot  packs  and  stimulants  are  indicated. 

Inflammation  of  the  Urethra,  Prostate,  or  Bladder.- — Inflammation 
of  the  stricture,  prostatitis,  or  cystitis  may  follow  as  a  result  of  injury 
to  the  urethra  or  vesical  neck  from  rough  or  careless  introduction  of 
instruments  or  from  failure  to  pay  due  regard  to  cleanliness.  The 
inflammation  may  extend,  in  addition,  from  the  urethra  down  the 
ejaculatory  ducts  and  set  up  an  epididymitis.  In  the  presence  of 
such  complications,  attempts  at  dilatation  should  cease  until  the 
acute  period  is  passed  and  appropriate  treatment  should  be  directed 
to  the  cure  of  the  complication. 

Hemorrhage, — At  times  considerable  hemorrhage  may  result  from 
the  passage  of  instruments.  This,  as  a  rule,  indicates  a  false  passage 
or  an  attempt  at  too  great  a  degree  of  dilatation  at  one  sitting.  Bleed- 
ing may  occur,  however,  in  some  cases  where  the  urethra  is  markedly 
congested  with  scarcely  any  injury  to  the  tissues.  The  bleeding 
usually  stops  of  its  own  accord.  If  excessive,  the  patient  should  be 
kept  quietly  in  bed  and  cold  applications  should  be  applied  to  the 
perineum. 

False  Passage. — Another  accident  that  may  result  from  the  use  of 
urethral  instruments  is  the  formation  of  a  false  passage  by  forcing 
the  instrument  through  the  urethral  wall  into  the  surrounding  tissues. 
It  is  more  liable  to  happen  when  using  rigid  instruments  of  small  size 
and  probably  occurs  more  frequently  than  is  recognized.  When  a 
false  passage  is  made,  there  will  generally  be  free  hemorrhage  at  the 
time  or  upon  withdrawal  of  the  instrument,  and  the  patient  will  com- 
plain of  severe  pain  and  may  show  signs  of  shock.  At  the  same  time, 
the  operator,  while  conscious  that  the  instrument  has  passed  the 


640  THE    URETHRA    AND    PROSTATE 

obstruction,  will  recognize  that  the  point  is  not  in  the  urethra  from  the 
direction  of  the  handle.  In  such  a  case,  if  an  examination  is  made  by 
the  rectum,  the  point  of  the  instrument  will  be  found  in  the  perineum 
near  the  rectal  wall.  Furthermore,  the  instrument,  if  it  be  a  rigid 
curved  one,  cannot  be  rotated  about  its  own  axis  as  would  be  the  case 
were  its  point  in  the  bladder. 

Following  such  an  accident,  if  the  patient  can  urinate,  the  treat- 
ment should  be  expectant  in  the  main;  that  is,  he  should  be  put  to  bed 
and  given  urinary  antiseptics  and  carefully  watched.  Should  extrava- 
sation of  urine  occur  or  an  abscess  develop,  prompt  and  free  drainage 
should  be  estabUshed  and  perineal  urethrotomy  should  be  performed. 

CONTINUOUS  DILATATION 

Continuous  dilatation  consists  in  inserting  a  fiUform  or  small 
bougie  through  a  stricture  and  leaving  it  in  place  for  twenty-four  or 
forty-eight  hours.  By  the  end  of  this  period  more  or  less  absorption 
of  the  stricture  has  taken  place,  so  that  there  is  some  dilatation,  and 
a  larger  instrument  may  then  be  inserted.  It  is  a  method  that  may 
be  sometimes  employed  for  securing  dilatation  of  tight  strictures  not 
amenable  to  gradual  dilatation,  and  is  worthy  of  trial  in  such  cases 
before  resorting  to  a  radical  cutting  operation.  The  method  has  its 
objections,  however,  in  that  it  is  necessary  to  keep  the  patient  under 
constant  observation  and  in  bed;  furthermore,  irritation  from  the 
instrument  in  the  urethra  is  apt  to  cause  urethritis  which  may  in  turn 
lead  to  cystitis.  The  method  is  contraindicated  in  the  presence  of 
cystitis  or  if  renal  complications  exist. 

Instruments. — Filiform  (see  Fig.  599)  or  soft  bougies  (see  Fig.  598) 
may  be  employed. 

Asepsis.^ — Rigid  asepsis  is,  of  course,  imperative.  The  instru- 
ments are  to  be  sterilized  as  already  described  (page  587).  The  penis 
and  meatus  are  washed  with  soap  and  water,  followed  by  a  i  to  5000 
bichlorid  of  mercury  solution.  The  urethra  should  be  irrigated  with 
a  I  to  5000  permanganate  of  potash  or  saturated  boric  acid  solution, 
and  the  bladder  should  be  likewise  irrigated  with  boric  acid  solution, 
if  possible,  upon  changing  the  instruments. 

Technic. — The  instrument  is  passed  through  the  stricture  after  the 
method  already  described  for  intermittent  dilatation  (page  636),  and 
is  then  securely  fastened  in  place.  There  are  several  methods  of  do- 
ing this,  but  the  following  is  the  simplest  and  most  effective:  Four 
pieces  of  adhesive,  each  about  4  inches  (12  cm.)  long  and  1/4  inch  (6 


CONTINUOUS   DILATATION 


641 


mm.)  wide  are  secured  to  the  bougie  (which  for  a  space  of  an  inch  (2.5 
cm.)  in  front  of  the  meatus  has  been  thoroughly  dried  and  from  which 
all  grease  has  been  removed)  in  such  a  way  that  one  strip  lies  upon 
the  dorsum,  one  on  the  ventral  surface,  and  one  on  either  lateral  sur- 
face of  the  penis.  When  a  foreskin  is  present,  it  is  drawn  down  over 
the  glans  and  each  strip  is  carried  over  it  and  caused  to  adhere  to  • 
the  penis.  An  additional  strip  of  adhesive  i  inch  (2.5  cm.)  wide 
is  placed  horizontally  about  the  penis  just  behind  the  corona  cover- 
ing the  four  small  strips  (Fig.  673).  This  strip  should  not  entirely 
encircle  the  penis,  thus  avoiding  any  danger  of  constricting  it.    Where 


Fig.  673. — Showing  the  method  of  securing  a  bougie  or  catheter  in  the  urethra. 
(After  Sinclair,  Polyclinic  Journal,  July,  1908.) 

there  is  no  foreskin,  a  piece  of  gauze  should  be  interposed  between  the 
glans  and  the  small  strips.  A  liberal  sterile  gauze  dressing  is  then 
wrapped  about  the  penis  and  the  protruding  instrument,  and  the 
whole  is  supported  by  means  of  a  T-bandage.  The  urine  escapes 
along  the  side  of  the  bougie  into  the  gauze,  which  should  be  changed 
when  saturated.  Within  twenty-four  or  forty-eight  hours  the  bougie 
is  removed,  and  the  stricture  will  be  found  sufficiently  stretched  to 
permit  the  easy  introduction  of  a  larger  instrument.  This  is  left  in 
for  the  same  length  of  time,  and  upon  its  removal  gradual  dilatation 
may  be  begun. 

When  there  is  retention  of  urine,  the  filiform  is  passed  as  before  and 
a  tunneled  catheter  is  passed  over  it  as  a  guide  into  the  bladder  (page 
638),  and  the  urine  is  drawn  off.  The  bladder  is  then  irrigated  and 
the  catheter  removed,  but  the  filiform  is  secured  in  place  as  described 
above.  Usually  urine  will  begin  to  pass  along  the  bougie  in  a  short 
while,  but  if  not  it  may  be  withdrawn  as  often  as  necessary  by  means 
of  a  tunneled  catheter. 


41 


CHAPTER  XX 
THE  BLADDER 

Anatomic  Considerations 

The  bladder  is  a  musculomembranous  reservoir  tor  the  reception  of 
urine,  lying  behind  the  pubes  and  in  front  of  the  rectum  in  the  male 
and  the  uterus  in  the  female.  The  bladder  may  be  described  as  hav- 
ing (i)  a  summit,  or  apex;  (2)  a  base,  or  fundus,  which  rests  upon  the 
rectum  and  into  which  open  the  ureters ;  (3)  a  body,  or  middle  portion ; 
and  (4)  a  neck,  or  constricted  portion,  opening  into  the  urethra.  It 
has  an  average  physiological  capacity  of  from  6  to  9  ounces  (180  to 
270  c.c),  and  a  normal  maximum  capacity  of  24  ounces  (720  c.c),  but, 
under  certain  pathological  conditions,  it  may  become  enormously 
distended  without  rupture.  Its  shape  and  position  depend  to  a  cer- 
tain extent  upon  whether  it  is  empty  or  full.  When  empty,  it  lies  well 
behind  the  pubes,  and  upon  median  section  appears  triangular  in  out- 
line; when  partially  filled,  it  becomes  rounded  in  outline;  and,  when 
completely  distended,  it  becomes  oval  and  rises  partly  from  the  pelvis 
into  the  abdominal  cavity. 

The  peritoneum  partially  covers  the  anterior  surface  and  sides  of 
the  bladder,  and  entirely  covers  the  superior  surface,  extending  pos- 
teriorly as  far  as  the  level  of  a  transverse  line  passed  between  the  upper 
limits  of  the  seminal  vesicles,  whence  it  is  reflected  to  the  rectum  in 
the  male,  while  in  the  female  it  is  reflected  to  the  uterus.  When  the 
bladder  becomes  distended,  the  peritoneum  is  carried  from  the  ante- 
rior abdominal  wall  with  it,  so  that  in  retention  of  urine  with  disten- 
tion it  becomes  possible  to  empty  the  viscus  by  passing  an  aspirator 
into  it  above  the  pubes  without  fear  of  entering  the  peritoneal  cavity 
(Fig.  674). 

Beneath  the  peritoneal  coat  lies  the  muscular  layer.  It  consists 
of  three  coats:  external,  middle,  and  internal.  The  external  is  com- 
posed of  fibers  arranged  longitudinally  and  in  thick  bundles  over  the 
anterior  and  posterior  surfaces,  but  forming  a  comparatively  thin 
layer  at  the  sides.  The  fibers  of  the  middle  coat  have  a  circular 
arrangement.  They  are  thickest  at  the  neck  where  they  form  the 
internal  vesical  sphincter.     The  internal  layer  is  thinner  than  either 

642 


ANATOMIC    COXSLDEIL\TIONS 


643 


Fig.  674. — Showing  the  space  above  the  pubes  through  which  it  is  possible  to  enter 
the  bladder  without  opening  into  the  peritoneum. 


Fig.  675. — The  interior  of  the  bladder,      i,  Trigone;  2,  orifice  of  ureter;  3,  mus- 
cular layer;  4,  mucous  membrane;  5,  interureteric  line;  6,  prostate  gland. 


044  THE  BLADDER 

of  the  others.  Some  of  its  fibers  are  arranged  longitudinally  and 
others  circularly. 

The  mucous  coat  is  composed  of  stratified  pavement  epithelium. 
It  is  of  a  pale  salmon  color.  When  the  bladder  is  distended,  the 
mucous  membrane  forms  a  smooth  lining  for  the  interior,  but  is  thrown 
up  into  thick  folds  when  the  viscus  is  empty,  except  over  the  portion 
known  as  the  trigone  where  it  is  always  smooth.  The  mucous  mem- 
brane of  the  bladder  is  comparatively  insensitive  to  touch  when  in  a 
normal  condition,  as  it  has  a  scant  nerve  supply,  the  most  sensitive 
portion  being  over  the  trigone.  The  trigone  is  a  smooth  triangular 
space  at  the  base  of  the  bladder,  the  apex  of  which  corresponds  to  the 
opening  of  the  urethra  and  the  base  to  a  line  passing  between  the 
orifices  of  the  two  ureters  (Fig.  675). 

The  ureters  pierce  the  bladder  wall  obliquely  and  appear  upon  the 
mucous  membrane  as  round  openings  or  oval  slits  directed  forward 
and  inward.  These  orifices  are  from  i  to  i  1/2  inches  (2.5  to  4  cm.) 
apart  and  about  i  inch  (2.5  cm.)  from  the  beginning  of  the  urethra. 


Diagnostic  Methods 

When  examining  a  case  of  suspected  bladder  disease  the  symptoms 
complained  of  should  first  receive  careful  attention.  In  addition  to 
the  usual  questions,  information  bearing  upon  the  act  of  urination 
should  be  sought,  ascertaining  whether  there  is  frequency  of  urination, 
whether  there  is  urgency,  whether  the  act  is  difficult,  whether  pain  is 
present  and,  if  so,  its  relation  to  the  passage  of  urine,  whether  the 
force  or  caliber  of  the  stream  is  changed,  etc.,  etc. 

Frequency  of  urination  is  common  in  all  bladder  affections  where 
the  mucous  membrane  is  inflamed.  It  is  also  a  symptom  of  vesical 
stone,  tumor,  foreign  body,  or  an  enlarged  prostate.  In  the  presence 
of  stone  this  symptom  is  more  marked  when  the  patient  is  up  and 
about  or  after  exertion,  while  in  the  case  of  an  enlarged  prostate  it  is 
more  pronounced  at  night.  Frequent  micturition  may,  however, 
occur  when  the  bladder  is  healthy,  as  in  diabetes,  in  hysteria,  in  those 
who  drink  large  quantities  of  water,  in  those  whose  urine  contains 
excessive  amounts  of  uric  acid  or  oxalates,  etc. 

Urgency  of  micturition,  or  the  feeling  of  being  compelled  to  pass 
urine  the  instant  the  desire  is  felt,  points  strongly  to  inflammation  of 
the  bladder  or  the  prostate.  Inflammation  or  irritation  of  the  urethra 
may  also  cause  it.     It  is,  however,  sometimes  observed  as  the  result 


ANATOMIC    CONSIDERATIONS  645 

of  certain  mental  emotions,  as  fright  or  apprehension,  or  mental  sug- 
gestions, such  as  the  sound  of  running  water.  Irritating  urine  and 
diseases  of  the  nervous  system  are  also  causes. 

With  a  history  of  painful  micturition,  it  is  important  to  determine 
the  seat  of  the  pain  and  the  exact  relation  it  bears  to  the  act  of  urina- 
tion. Pain  from  prostatitis  is  generally  felt  in  the  perineum  or  rec- 
tum, pain  in  bladder  disease  is  felt  over  the  pubes,  in  kidney  disease  in 
the  loins.  A  vesical  calculus,  however,  will  frequently  cause  pain  in 
the  head  of  the  penis.  Pain  at  the  beginning  of  urination,  as  a  rule, 
points  to  some  obstruction  to  the  outflow  of  urine  or  to  inflammation 
of  the  urethra,  or  it  may  be  the  result  of  very  irritating  urine.  If  it 
occurs  during  micturition,  it  may  be  caused  by  inflammation  of  the 
urethra,  prostate,  or  bladder  wall.  Pain  at  the  end  of  urination  occurs 
when  a  vesical  calculus  is  present  or  when  there  is  inflammation  in- 
volving the  neck  of  the  bladder  or  the  prostate.  In  acute  prostatitis 
pain  is  also  present  upon  defecation.  When  pain  is  present  in  the 
intervals  between  the  acts  of  urination,  it  may  be  caused  by  a  vesical 
calculus,  tumors,  or  prostatic  abscess.  When  such  pain  is  increased 
upon  exertion  and  entirely  relieved  by  rest  in  the  dorsal  position,  it  is 
believed  by  some  writers  to  be  pathognomonic  of  vesical  calculus. 

Difficulty  of  urination,  as  a  rule,  indicates  stricture  of  the  urethra 
or  an  enlarged  prostate.  Changes  in  the  caliber  of  the  stream  gener- 
ally point  to  stricture.  In  the  presence  of  enlarged  prostate,  disease 
of  the  bladder  wall,  and  in  some  nervous  affections,  the  force  of  the 
stream  may  be  greatly  diminished,  so  much  so  as  to  amount  to  a  mere 
dribbling.  A  vesical  calculus  may  at  times  cause  a  sudden  stoppage 
of  the  stream,  and  this  is  frequently  accompanied  by  sharp 
pain. 

While  a  complete  history  should  always  be  obtained,  at  the  same 
time  too  much  importance  should  not  be  placed  upon  symptomatology 
in  the  diagnosis  of  vesical  affections.  The  symptoms  are  often  decep- 
tive, as  they  may  be  common  to  diseases  involving  the  bladder,  kid- 
neys, or  urethra.  Even  when  they  clearly  point  to  the  bladder  as 
their  seat  of  origin,  they  are  sometimes  of  but  little  value  in  differen- 
tiating between  the  various  morbid  conditions  that  may  affect  this 
organ.  An  accurate  diagnosis  can  only  be  arrived  at  by  a  physical 
examination  along  the  lines  detailed  below. 

The  methods  available  for  examination  of  the  bladder  include 
urinalysis,  inspection,  percussion,  palpation,  sounding,  cystoscopy, 
tests  of  the  capacity,  the  sufficiency,  and  the  absorption  power  of  the 
bladder,  and  the  X-rays. 


646  THE  BLADDER 

EXAMINATION  OF  THE  URINE 

A  complete  chemical,  microscopical,  and  bacteriological  examina- 
tion of  the  urine  should  be  made  in  all  cases  of  suspected  disease  of 
the  bladder  or  kidneys.  The  proper  method  of  collecting  the  speci- 
men for  such  examination  has  been  previously  described  (page  252). 
but  it  is  outside  the  province  of  this  work  to  describe  urinalysis;  for 
this  the  reader  is  referred  to  some  of  the  numerous  works  devoted  to 
the  subject.  The  diagnostic  significance  of  modifications  in  the  nor- 
mal condition  of  the  urine  as  far  as  applies  to  vesical  and  renal  disease 
will,  however,  be  briefly  considered. 

The  quantity  of  urine  passed  normally  by  a  healthy  adult  amounts 
on  an  average  to  50  ounces  (1500  c.c.)  in  twenty-four  hours,  but  this 
may  be  greatly  modified  even  in  health,  depending  upon  the  season  of 
the  year,  the  quantity  of  water  imbibed,  the  amount  of  exercise  taken, 
the  condition  of  the  nervous  system,  etc.,  etc.  In  certain  diseases,  as 
fevers,  in  affections  accompanied  by  night-sweats  or  diarrhea,  chronic 
parenchymatous  and  acute  nephritis,  in  blockage  of  a  ureter  by  an 
impacted  stone  or  by  a  twist,  in  shock,  hemorrhage,  etc.,  the  output 
of  urine  may  be  greatly  decreased  (ohguria).  On  the  other  hand,  an 
increased  quantity  of  urine  (polyuria)  will  be  found  in  hysteria,  in 
the  presence  of  interstitial  changes  in  the  kidney,  from  the  use  of 
diuretics,  in  diabetes,  in  renal  tuberculosis,  in  pyelitis,  etc. 

In  bladder  affections  the  daily  output  of  urine  generally  remains 
unchanged  and,  in  the  presence  of  marked  changes  in  this  respect, 
involvement  of  the  kidneys  or  some  constitutional  disease  may  be 
implied. 

The  specific  gravity  of  the  urine  for  a  normal  individual  is  fixed  at 
1. 018  to  1.025  ^t  60°  F.  (16°  C).  The  specific  gravity  is  closely 
related  to  the  amount  of  solids  excreted,  so  to  be  of  value  the  test 
should  be  applied  to  a  mixture  of  the  urine  voided  during  twenty-four 
hours. 

In  diseases  of  the  bladder  the  specific  gravity  is  unaffected,  but  in 
renal  disease  it  may  be  markedly  changed.  A  low  specific  gravity 
and  an  increased  output  of  urine,  when  the  bladder  is  diseased,  points 
strongly  to  pyelitis  or  pyelonephritis. 

The  odor  of  urine  is  faintly  aromatic,  the  more  marked  the  greater 
the  proportion  of  solids.  The  taking  of  such  drugs  as  copaiba,  cubebs, 
turpentine,  and  sandalwood  modify  this  characteristic  odor.  In  dia- 
betic coma  the  odor  of  the  urine  resembles  that  of  chloroform  from 
the  presence  of  acetone  and  diacetic  acid.     Urine  that  has  undergone 


EXAMINATION   OF   THE    URINE  647 

ammoniacal  decomposition,  as  is  frequently  the  case  in  chronic  cysti- 
tis, has  the  characteristic  and  offensive  odor  of  stale  urine.  Urine 
coming  from  a  bladder  which  communicates  with  the  rectum  by  a 
rectovesical  fistula  has  an  odor  of  skatol.  In  the  presence  of  ulcera- 
tions within  the  bladder,  especially  ulcerating  tumors,  the  urine  will 
be  foul-smelling  and  may  even  have  a  distinct  odor  of  putrefaction. 

The  color  of  the  urine  is  a  hght  or  dark  amber  depending  upon  the 
concentration.  The  presence  of  blood  gives  the  urine  a  bright  red  or 
reddish  black  hue,  depending  upon  whether  the  hemorrhage  is  recent 
or  old.  Bile  gives  a  dark  yellow  or  brownish  color  with  a  greenish 
tinge.  In  chyluria  the  urine  appears  milky.  Fevers  render  the  urine 
darker  than  normal.  Various  drugs  may  also  modify  the  color,  thus 
senna,  rhubarb,  and  santonin  may  color  the  urine  a  golden-yellow 
or  deep  red  hue,  methylene  blue  gives  a  greenish-blue  color,  and 
poisoning  from  carbohc  acid,  chlorate  of  potash,  or  creosote  makes 
the  urine  smoky  or  black. 

Transparency. — Normal  urine  should  be  clear  and  transparent 
when  voided.  In  bladder  diseases  the  urine  is,  as  a  rule,  turbid. 
Turbidity  may  be  caused  by  urates,  phosphates,  blood,  pus,  epithe- 
lium, chyle,  or  bacteria.  The  turbidity  caused  by  urates  disappears 
upon  heating  the  urine,  that  due  to  phosphates  clears  up  upon  the 
addition  of  one  or  two  drops  of  acetic  acid. 

In  bacteriuria,  as  is  seen  after  the  passage  of  unclean  instruments, 
the  turbidity  is  slight  and  remains  unchanged  upon  standing,  upon  the 
application  of  heat,  or  in  the  presence  of  acetic  acid.  The  condition 
is  readily  recgonized  by  the  aid  of  the  microscope. 

The  turbidity  produced  by  pus  is  increased  upon  heating  the  urine, 
and  does  not  disappear  upon  the  addition  of  an  acid.  Furthermore, 
upon  allowing  such  a  specimen  to  stand  a  few  hours,  it  will  be  found 
that  the  pus  settles  to  the  bottom  leaving  the  rest  of  the  fluid  clear. 
A  simple  test  for  the  presence  of  pus  is  to  add  a  little  solution  of  potas- 
sium hydrate  to  the  suspected  specimen;  in  the  presence  of  pus  a 
gelatinous  precipitate  is  formed. 

The  reaction  of  urine  is  normally  slightly  acid.  The  acidity  is 
increased  in  fevers,  gout,  lithemia,  rheumatism,  chronic  B rights  dis- 
ease, etc.,  and  upon  a  diet  composed  chiefly  of  proteids.  A  vegetable 
diet  and  large  quantities  of  fluids  render  the  urine  neutral  or  alkaline. 

In  diseases  of  the  bladder  the  urine  may  be  acid  or  alkaline,  thus 
in  acute  cystitis  the  urine  is  usually  acid.  In  chronic  cystitis  it  may 
be  either  acid  or  alkaline,  always  the  latter  in  the  presence  of  ammoni- 
acal fermentation,  but  when  due  to  the  gonococcus,  tubercle  baoillus. 


648  THE    BLADDER 

or  colon  bacillus  it  is  acid.  In  uncomplicated  cases  of  pyelitis  and 
pyelonephritis  the  urine  also  has  an  acid  reaction. 

Alhiiminuria. — Albumin  in  the  urine  is  not  to  be  considered  an 
invariable  sign  of  kidney  disease.  It  may  result  from  a  number  of 
local  causes,  such  as  blood,  pus,  prostatic  secretion,  etc.,  due  to  an 
inflammation  involving  the  kidney  pelvis,  ureter,  bladder,  prostate, 
or  urethra,  without  the  existence  of  organic  disease  of  the  kidney. 
Furthermore,  a  transient  albuminuria  is  not  infrequently  the  result 
of  the  diet,  the  amount  of  exercise  taken,  ner\-ous  shocks,  toxins  in 
the  blood,  etc.  So  that  it  becomes  of  the  greatest  importance  to 
decide  whether  an  albuminuria  is  of  renal  origin  or  is  the  result  of 
other  pathological  conditions,  and  sometimes  this  is  a  difficult  matter. 
The  two  may  exist  together. 

Hematuria. — Blood  in  the  urine  may  have  its  source  in  any  part  of 
the  genitourinary  tract,  as  the  urethra,  prostate,  bladder,  ureters,  or 
kidneys.  While  it  is  not  always  possible  to  determine  the  source  of 
the  hemorrhage  from  an  examination  of  the  urine,  there  are  certain 
characteristic  differences  in  hemorrhages  from  these  different  regions. 

Urethral  hemorrhage  may  arise  from  acute  urethritis  or  inflamed 
strictures,  or  may  follow  traumatism  to  the  canal,  the  passage  of  in- 
struments, etc.  In  urethral  hemorrhage,  if  the  source  is  from  in  front 
of  the  compressor  urethras  muscle,  the  blood  appears  independently 
of  urination,  and  may  escape  from  the  meatus  freely,  in  drops,  or  in 
the  form  of  long  clots.  If  from  the  posterior  urethra,  the  blood  finds 
its  way  backward  into  the  bladder  and.  when  of  considerable  quantity, 
uniformly  discolors  the  urine.  If,  however,  the  posterior  hemorrhage 
is  sHght,  the  first  and  last  portions  of  the  urine  passed  may  be  blood- 
tinged  while  the  intermediary  portion  will  be  clear. 

Vesical  hemorrhage  may  follow  the  sudden  and  complete  empty- 
ing of  the  bladder  in  retention,  or  it  may  be  due  to  trauma,  the  pass- 
age of  instruments,  varicosities,  stone,  inflammation,  ulcer,  tubercu- 
losis, tumors,  etc.  The  urine  in  a  recent  vesical  hemorrhage  may  be 
comparatively  clear  at  first,  or  only  slightly  discolored,  becoming 
more  so  as  the  bladder  is  emptied,  until  it  finally  has  a  bright  red  color 
or  consists  of  almost  pure  blood.  It  may  contain  large  clots  which 
have  no  definite  shape,  and.  if  long  retained,  they  appear  black  and 
tarry.     The  reaction  of  the  urine  is  generally  alkaline. 

Renal  hematuria  may  be  due  to  inflammation,  congestion,  trauma, 
stone,  tuberculosis,  tumors,  the  use  of  strong  diuretics,  etc.,  etc.  The 
blood  will  be  thoroughly  mixed  with  the  urine,  imparting  to  the  latter 
a  smoky  tint  or  deep  red-brown  color.     It  will  be  found  that  the  cor- 


EXAMINATION    OF    THE    URINE  649 

puscles  are  greatly  changed  and  without  coloring  matter,  often  appear- 
ing as  mere  shadows,  but  in  cases  of  ruptured  kidney  or  in  severe  renal 
hemorrhage  from  other  cause,  they  may  remain  unaltered  and  the 
urine  will  be  much  lighter  in  color.  The  urine  during  renal  hemor- 
rhage and  just  after  is  generally  acid  in  reaction  unless  the  bleeding 
has  been  severe  or  pus  is  present.  Large  clots  are  seldom  formed  un- 
less the  blood  coagulates  after  reaching  the  bladder,  but  there  may  be 
found  casts  of  the  kidney  tubules  or  cylindrical-shaped  clots  from  the 
ureters. 

A  more  positive  diagnosis  between  hematuria  of  renal  origin  and 
that  of  the  bladder  may  be  made  by  introducing  a  catheter  and  thor- 
oughly washing  out  the  bladder  with  a  warm  normal  salt  solution, 
being  careful  to  wash  out  all  the  clots.  If  the  blood  is  of  renal  origin, 
the  last  washings  will  consist  of  clear  fluid  and  will  remain  clear  until 
more  blood  flows  from  the  ureters.  If,  on  the  other  hand,  the  bleed- 
ing arises  from  the  bladder,  it  will  be  found  impossible  to  completely 
free  the  fluid  from  blood. 

By  means  of  a  cystoscopic  examination  (page  659)  the  bladder  may 
be  excluded  as  the  source  of  the  blood  if  it  is  found  free  from  disease, 
or  it  may  be  possible  to  see  blood  escaping  from  one  or  other  ureter. 
(See  also  the  absorption  test,  page  659.) 

Pyuria. — Pus  in  the  urine  is  a  common  accompaniment  of  bladder 
diseases  and  also  those  affecting  the  urethra  and  kidneys.  Pyuria  is 
a  symptom  of  suppuration  or  catarrh  in  the  genitourinary  tract;  thus 
it  will  be  found  in  pyonephritis,  pyelitis,  tuberculosis,  cystitis,  ure- 
thritis, etc.  It  is  characterized  by  cloudy  urine  in  which  a  thick 
yellow  sediment  settles  upon  standing. 

A  differential  diagnosis  between  urethral  pus  and  bladder  pus  may 
be  made  by  having  the  patient  void  his  urine  in  two  glasses  (page  580) . 
If  the  urethra  is  the  source,  the  first  glass  of  urine  will  be  found  cloudy 
and  the  contents  of  the  second  glass  clear  or  nearly  so.  When  the 
bladder  is  affected  the  contents  of  both  glasses  will  be  equally  cloudy. 

In  deciding  between  vesical  and  renal  pyuria,  it  should  be  borne  in 
mind  that  in  the  former  condition  the  amount  of  albumin  will  be 
slight  and  there  will  be  no  renal  casts,  but  bladder  epithelium  will  be 
found;  while  in  urine  containing  pus  from  the  kidney  albumin  will  be 
found  in  a  greater  proportion  than  can  be  accounted  for  by  the 
amount  of  pus,  and  casts  may  be  present.  The  use  of  the  catheter  or 
cystoscope  will,  however,  furnish  more  exact  evidence  as  to  the  sourc3 
of  the  pyuria. 

To  apply  the  first  test,  the  bladder  is  thoroughly  washed  with  a 


6^o 


THE   BLADDER 


warm  normal  salt  or  boric  acid  solution  through  a  catheter  until  the 
fluid  returns  clear.  The  catheter  is  then  clamped  and  allowed  to 
remain  in  place  ten  or  fifteen  minutes,  and  what  urine  has  entered  the 
bladder  in  the  meantime  is  drawn  off.  If  this  last  specimen  is  again 
turbid  we  may  conclude  that  the  pus  comes  from  the  kidneys. 

On  cystoscopic  examination,  if  the  bladder  be  found  free  from 
disease,  this  evidence  points  to  the  kidney  as  the  source  of  pus.  The 
diagnosis  may  be  made  absolute  if  pus  is  seen  exuding  from  the  ure- 
ters or  a  sample  of  urine  obtained  by  ureteral  catheterization  contains 
pus. 

INSPECTION 

Inspection  of  the  bladder  without  the  aid  of  instruments  is  ex- 
tremely limited  in  value.     By  inspection  of  the  abdomen,  it  is  possi- 


FiG.  676. — Vaginal  inspection  of  the  bladder.     (Ashton.) 

ble  to  recognize  a  distention  of  the  bladder,  and,  in  the  female,  hy 
means  of  a  vaginal  inspection,  some  information  as  to  the  condition 
of  the  floor  of  the  bladder  may  be  gained. 

Position  of  Patient. — For  ordinary  abdominal  inspection  the 
patient  Hes  flat  on  the  back  with  the  body  uncovered  from  the  um- 
bilicus to  the  knees,  and  with  the  legs  extended  in  the  same  plane  as 
the  body. 

For  inspection  through  the  vagina  the  patient  should  be  in  the 
dorsal  posture. 

Technic. — i.  Abdominal  Inspection. — The  examiner  takes  his 
position  upon  one  side  of  the  patient  and  carefully  notes  any  change 


PALPATION  651 

in  the  size  or  shape  of  the  hypogastrium.  A  distended  bladder 
appears  as  an  ovoid  tumor  with  the  narrow  end  down,  situated  above 
the  symphysis  generally  in  the  median  line. 

2.  Vaginal  Inspection. — The  examiner  sits  facing  the  vulva,  and, 
by  retracting  the  perineum  with  the  index-finger  of  the  left  hand  in- 
troduced within  the  vagina  (Fig.  676),  the  anterior  vaginal  wall  is  ex- 
posed for  inspection.  In  this  way  a  displacement  of  the  bladder,  pro- 
trusion from  distention,  or  a  vesicovaginal  fistula  may  be  recognized. 

PERCUSSION 

Percussion  of  the  bladder  is  chiefly  of  use  in  determining  the  pres- 
ence or  absence  of  distention.  The  percussion  note  over  the  hypo- 
gastrium is  normally  tympanitic.  When  the  bladder  becomes  dis- 
tended with  fluid,  there  will  be  a  fluctuating  tumor  above  the  symphy- 
sis which  gives  a  fiat  percussion  note  and  tympany  at  the  sides.  If, 
however,  coils  of  intestine  fill  the  space  between  the  bladder  and  the 
abdominal  wall,  as  is  sometimes  the  case  where  the  intestines  become 
adherent  as  the  result  of  pelvic  peritonitis,  percussion  will  furnish  but 
imperfect  information,  as  a  tympanitic  note  may  be  obtained  and 
yet  the  bladder  be  distended.  Any  doubt  as  to  the  presence  of 
distention  should  be  immediately  settled  by  passing  a  catheter  into 
the  bladder. 

PALPATION 

In  the  case  of  thin  individuals  with  relaxed  abdominal  walls  pal- 
pation will  often  give  valuable  information,  but  in  fat  or  very  muscu- 
lar patients  it  is  of  limited  use.  The  palpation  may  be  performed 
abdominally  or  bimanually.  The  latter  method  yields  the  most 
valuable  information.  Distention,  foreign  bodies,  calculi,  tumors, 
and  tender  areas  may  be  thus  recognized,  and  an  idea  as  to  the  thick- 
ness and  sensibility  of  the  bladder  walls  may  be  obtained.  It  is  an 
especially  useful  method  to  employ  in  examining  the  bladders  of 
children. 

Digital  palpation  of  the  bladder  by  means  of  a  finger  introduced 
through  a  perineal  or  suprapubic  wound  or  through  the  urethra  in  the 
female  are  methods  now  rarely  employed  for  diagnosis  alone,  as  we 
have  other  equally  efficient  and  more  simple  means  of  examination. 

Position  of  Patient.- — For  abdominal  palpation  the  patient  should 
be  in  the  dorsal  posture  with  the  thighs  flexed  and  the  body  uncovered 
from  the  umbilicus  down.  This  or  the  knee-chest  posture  may  be 
employed  for  bimanual  examination. 


652 


THE   BLADDER 


Anesthesia. — In  stout  individuals  or  those  with  rigid  abdominal 
walls,  it  may  be  impossible  to  make  a  satisfactory  bimanual  examina- 
tion without  the  aid  of  general  anesthesia. 


Fig.  677. — Abdominal  palpation  of  a  distended  bladder. 


Fig.  678. — Bimanual  palpation  of  the  bladder. 

Technic.  i.  Abdominal  Palpation. — The  examiner  stands  upon 
the  left  side  of  the  patient,  and,  placing  his  right  hand  flat  upon  the 
abdomen  just  above  the  pubes,  gently  palpates  the  hypogastric  region 
by  means  of  his  finger  tips.     In   thin  individuals,  if   distention  is 


SOUNDING  653 

present,  a  fluctuating  tumor  will  be  recognized.  By  requesting  the 
patient  to  breathe  deeply  with  the  mouth  open  and  at  the  same  time 
pressing  the  ulnar  border  of  the  hand  deeply  toward  the  pelvis,  it  is 
often  possible  to  outline  the  swelling  of  a  distended  bladder  more 
distinctly  (Fig.  677).  Such  manipulation  will  frequently  cause  the 
patient  to  evince  a  desire  to  urinate. 

2.  Bimanual  Palpation. — The  bladder  should  be  first  emptied. 
The  index-finger  of  the  right  hand  or  the  index  and  middle  fingers,  if 
possible,  are  introduced  into  the  rectum  in  the  male  or  the  vagina 
in  the  female,  after  first  being  well  lubricated.  The  four  fingers  of 
the  left  hand  are  then  placed  above  the  symphysis,  and,  while  they 
make  counter  pressure  toward  the  base  of  the  bladder,  the  entire 
viscus  is  palpated  bimanually  (Fig.  678). 

SOUNDING 

Palpation  of  the  interior  of  the  bladder  by  means  of  a  suitable 
sound  is  a  method  of  exploration  employed  in  cases  of  suspected 
stone,  foreign  bodies,  or  tumors.  The  sound  is  also  of  value  in 
testing  the  sensitiveness  of  the  bladder  walls  and  in  estimating  the 


Fig.  679. — Thompson  stone  searcher. 

amount  of  intravesical  enlargement  of  the  prostate  (page  585)  and  in 
the  diagnosis  of  cystocele  in  the  female. 

While  sounding  is  a  fairly  reliable  method  in  searching  for  a  stone, 
there  are  certain  difficulties  and  sources  of  error  that  should  be  borne 
in  mind.  A  stone  may  be  encrusted  with  blood  and  mucus  and  so  be 
missed  entirely,  or  it  may  be  encysted  with  only  such  a  small  por- 
tion exposed  that  it  may  be  difficult  to  reach  it,  or  it  may  lie  behind 
an  enlarged  middle  lobe  of  the  prostate.  Very  small  stones  may  like- 
wise be  missed  or  they  may  be  so  light  that  the  slight  shock  imparted 
by  contact  of  the  instrument  is  unnoticed.  A  tumor  or  a  contracted 
thick  bladder  wall  encrusted  with  lime  salts  or  phosphates  may  give 
a  sensation  that  is  confused  with  the  click  of  a  stone. 

Instruments. — For  sounding  the  male  bladder  a  Thompson  metal- 
lic searcher  (Fig.  679)  is  employed.  This  instrument  has  a  fairly 
large  beak,  flattened  from  side  to  side,  which  joins  the  shaft  at  an 


654  THE  BLADDER 

angle  of  120  degrees.  The  shaft  should  be  slender — 12  to  15  French 
scale — so  it  can  be  readily  moved  back  and  forth  or  rotated  from 
side  to  side  within  the  urethra.  The  handle  of  the  instrument  is 
supplied  with  a  guide  which  indicates  the  direction  of  the  beak. 

Asepsis. — The  sound  is  boiled  for  five  minutes  in  a  i  per  cent, 
sodium  carbonate  solution.  The  external  genitals  are  cleansed  with 
soap  and  water  followed  by  a  i  to  5000  bichlorid  of  mercury  solution. 
The  hands  of  the  operator  should  be  sterilized  in  the  usual  way.  The 
urethra  should  be  irrigated  with  a  saturated  solution  of  boric  acid  or 
a  I  to  5000  permanganate  of  potassium  solution.  The  bladder  is 
emptied  and  irrigated  with  boric  acid  solution. 

Position  of  Patient. — The  patient  should  be  in  a  recumbent  posi- 
tion with  the  hips  raised  several  inches  higher  than  the  head  and  the 
thighs  extended  fiat. 

Preparations  of  the  Patient. — The  rectum  should  be  empty. 
About  4  ounces  (120  c.c.)  in  an  adult  and  2  ounces  (60  c.c.)  in  a  child 
of  a  saturated  boric  acid  solution  or  a  normal  salt  solution  should 
be  introduced  into  the  bladder,  so  as  to  permit  easy  movement  of 
the  searcher  and  to  prevent  the  stone  from  being  concealed  in  the 
folds  of  mucous  membrane. 

Anesthesia — As  a  rule,  no  anesthesia  is  necessary.  In  sensi- 
tive cases  the  instillation  of  a  few  drops  of  a  2  per  cent,  solution  of 
cocain  into  the  posterior  urethra  vriR  suffice,  or  the  bladder  may  be 
filled  with  5  ounces  (150  c.c.)  of  a  warm  o.i  per  cent,  solution  of 
cocain  to  which  is  added  20  drops  (1.25  c.c.)  of  adrenalin  chlorid. 
This  is  to  be  retained  fifteen  to  twenty  minutes.  If  the  bladder  is 
extremely  irritable  and  the  patient  nervous,  a  general  anesthetic 
may  be  administered.  In  children  a  general  anesthetic  is  usually 
necessary. 

Technic. — The  instrument  is  well  lubricated  with  lubrichondrin 
or  one  of  the  other  Irish-moss  preparations  and  is  introduced  in  the 
same  manner  as  a  sound  (page  587).  When  the  beak  of  the  instru- 
ment reaches  the  triangular  ligament,  the  fingers  of  the  left  hand  are 
appHed  to  the  perineum  and  assist  in  guiding  the  point  into  the  open- 
ing. The  handle  of  the  sound  is  then  brought  dowTi  between  the 
thighs  and  the  instrument  is  at  the  same  time  gently  pushed  into 
the  bladder.  As  the  instrument  traverses  the  fixed  curve  of  the 
urethra,  pressure  should  be  made  over  the  region  of  the  pubes  to 
relax  the  suspensory  ligament  of  the  penis  (see  Fig.  605).  To  be 
sure  the  point  is  within  the  bladder,  the  instrument  should  be  intro- 
duced a  distance  of  about  8  inches  (20  cm.). 


SOUNDING 


655 


A  systematic  examination  of  the  entire  bladder  is  then  per- 
formed. The  instrument,  being  held  lightly  between  the  thumb 
and  the  forefinger  of  the  right  hand,  is  first  inserted  to  the  full  length, 
and  is  then  slowly  withdrawn,  rotating  the  beak  from  side  to  side, 
so  that  the  point  of  the  sound  is  brought  into  contact  with  every  por- 
tion of  the  bladder  wall.  In  this  way  any  thickness  or  rigidity  of 
the  bladder  wall,  as  is  found  in  hypertrophy,  chronic  inflammatory 
conditions,  and  in  the  presence  of  firm  growths,  may  be  recognized. 
In  the  same  manner  the  sensitiveness  of  the  organ  may  be  tested. 
Normally,  the  bladder  has  but  little  sensation  to  touch  except  in  the 
region  of  the  trigone.     In  cases  of  posterior  urethritis  this  region  may 


Fig.  680. — Palpation  of  a  stone  lodged  above  the  vesical. opening. 

be  markedly  hyperesthetic.  Local  areas  of  increased  sensitiveness 
point  to  ulceration  or  new  growths,  while  in  cases  of  cystitis  the  entire 
bladder  will  be  sensitive. 

In  examining  for  suspected  stone  the  search  should  be  carried  out 
in  the  same  systematic  manner,  carrying  the  instrument  to  the  fun- 
dus first  and  then  tapping  each  lateral  wall  in  succession  as  the  in- 
strument is  withdrawn  to  the  vesical  neck.  The  upper  wall  of  the 
bladder  is  then  palpated  by  depressing  the  handle  of  the  instrument 
well  down  between  the  thighs,  and  as  an  aid  the  bladder  wall  may  be 
depressed  toward  the  instrument  by  means  of  the  free  hand  placed 
above  the  pubes.  In  this  way  a  stone  located  above  the  vesical  open- 
ing may  be  located  (Fig.  680).  The  beak  of  the  sound  is  then  rotated 
and  turned  downward.  In  doing  this,  if  the  point  catches  in  the 
mucous  membrane,  the  handle  should  be  depressed  so  as  to  lift  the 
beak  clear  of  the  floor.     The  posterior  prostatic  region  is  then  ex- 


6;;6 


THE   BL.ADDER 


plored.  Should  the  prostate  be  enlarged,  the  handle  of  the  instru- 
ment should  be  raised  somewhat,  and,  with  a  finger  in  the  rectum, 
it  will  be  possible  to  bring  a  stone,  if  one  is  present,  within  reach  of 
the  instrument  (Fig.  68i). 

WTien  the  sound  strikes  a  stone,  the  examiner  will  recognize  the 
fact  by  a  distinct  click  that  may  be  heard  as  w^ell  as  felt.  Some 
idea  as  to  the  consistency  of  the  stone  may  be  gained  from  the  sharp- 
ness of  the  ring;  a  high-pitched  metallic  click  generally  indicates  a 
hard  stone  (oxalate),  while  a  dull  low-pitched  sound  would  indicate 
a  soft  stone  (urate).     It  is  also  possible  to  determine  whether  a 


Fig.  68 1. — Palpation  of  a  stone  lodged  behind  the  prostate  with  the  aid  of  a  finger 

in  the  rectum. 

stone  is  rough  or  smooth  from  the  sensation  imparted  as  the  beak 
of  the  instrument  is  drawm  over  its  surface.  If  possible  it  should 
be  ascertained  w^hether  a  stone  is  movable  or  fixed  by  attempting  to 
dislodge  it  with  the  beak  of  the  instrument  or  by  changing  the  posi- 
tion of  the  patient,  that  is,  after  the  stone  is  located,  the  sound  is 
withdrawn  and  the  patient  is  put  in  the  knee-chest  posture;  on  re- 
suming the  dorsal  position,  the  instrument  is  again  inserted  and  any 
change  in  the  position  of  the  stone  is  noted. 

To  determine  the  size  of  the  stone,  the  beak  of  the  instrument  is 
carried  over  the  posterior  surface  and  the  position  of  the  meatus  is 
marked  on  the  shaft.  The  instrument  is  then  slowdy  w^ithdrawn, 
tapping  the  stone  the  while,  until  the  anterior  border  is  reached  and 
the  relation  of  the  meatus  to  the  shaft  is  again  noted.  Subtracting 
the  latter  measurement  from  the  first  one  gives  approximately  the 


TEST  OF  THE  BLADDER  CAPACITY 


657 


length  of  the  stone  in  its  antero-posterior  diameter.  The  transverse 
diameter  may  be  Kkewise  estimated  by  tapping  the  stone  from  side 
to  side. 

At  the  completion  of  the  operation  the  instrument  is  removed  by 
a  reversal  of  the  steps  taken  in  its  insertion,  and  the  bladder  is 
irrigated  with  a  warm  saturated  solution  of  boric  acid,  followed  by  a 
deep  urethral  instillation  of  i  to  1500  silver  nitrate  solution. 

TEST  OF  THE  BLADDER  CAPACITY 

By  distending  the  bladder  with  fluid  its  capacity  is  readily  esti- 
mated, and  from  this  it  mav  be  determined  whether  the  bladder  is 


Fig.  682. — Catheter  and  syringe  for  estimating  the  bladder  capacity. 


Fig.  683. — Alethod   of   distending   the   bladder   with   fluid   when   estimating   its 

capacity. 

normal,  atonic,  or  contracted.  If  large  quantities  of  solution  can  be 
injected  without  inducing  contractions,  it  may  be  inferred  that  atony 
or  paralysis  exists;  but  if,  on  the  other  hand,  the  bladder  is  in  an  in- 
flamed condition  or  is  contracted,  it  vnil  often  not  be  possible  to 
inject  more  than  an  ounce  (30  c.c.)  or  so  without  the  patient  com- 
plaining of  distention. 
42 


658  THE  BLADDER 

This  test  is  also  useful  in  the  diagnosis  of  a  ruptured  bladder. 
By  injecting  a  definite  amount  of  solution  into  the  bladder  and  noting 
the  quantity  that  returns,  the  presence  or  absence  of  rupture  may  be 
readily  recognized.  In  performing  this  test,  however,  it  is  neces- 
sary to  inject  6  to  8  ounces  (180  to  250  c.c.)  of  fluid,  as  small  amounts 
may  give  misleading  results. 

Apparatus. — An  ordinary  soft-rubber  catheter  for  the  male  or  a 
glass  catheter  for  the  female  and  a  large  syringe,  such  as  a  Janet  or 
Record  (Fig.  682),  are  required. 

Asepsis. — The  apparatus  is  sterilized  by  boiling  and  the  exami- 
ner's hands  are  to  be  thoroughly  cleansed.  The  external  genitals 
are  washed  with  soap  and  water,  followed  by  a  i  to  5000  solution 
of  bichlorid  of  mercury,  and  the  urethra  is  irrigated  with  a  satu- 
rated solution  of  boric  acid  or  a  i  to  5000  solution  of  potassium 
permanganate. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  position 
upon  a  flat  table. 

Technic. — The  catheter,  well  lubricated  with  lubrichondrin,  is 
introduced  into  the  bladder  and  all  the  urine  is  drawn  off.  The 
syringe  is  then  filled  with  a  warm  (100°  F.  (38°  C.))  saturated  solution 
of  boric  acid  or  normal  salt  solution,  and  the  solution  is  slowly  in- 
jected into  the  bladder  (Fig.  683).  As  soon  as  the  patient  complains 
of  distention,  the  injection  is  stopped  and  the  quantity  of  fluid  that 
has  entered  the  bladder  is  estimated.  The  syringe  is  then  discon- 
nected from  the  catheter  and  the  fluid  is  allowed  to  escape  from  the 
bladder  through  the  catheter. 

ESTIMATION  OF  RESIDUAL  URINE 

Normally,  with  micturition  the  bladder  empties  itself  almost 
completely,  but,  if  the  evacuation  of  urine  is  interfered  with  by 
obstruction  from  a  stricture  or  an  enlarged  prostate  or  from  the  con- 
dition of  the  bladder  itself,  as,  for  example,  in  atony,  cystocele,  etc., 
the  evacuation  will  be  incomplete  and  more  or  less  residual  urine 
will  remain.  The  amount  of  residual  urine  often  has  a  bearing  upon 
the  prognosis  as  well  as  the  treatment  to  be  pursued  in  a  given  case, 
and  its  estimation  is  thus  of  some  importance. 

Apparatus. — All  that  is  required  is  a  ^Mercier  catheter  with  a 
coude  curve  and  a  glass  graduate. 

Asepsis. — The  catheter  is  sterilized  by  immersion  in  a  i  to  20 
carbolic  acid  solution  followed  by  rinsing  in  sterile   water.     The 


THE    ABSORPTION    TEST  659 

external  genitals  are  cleansed  in  the  usual  way,  and  the  urethra  is 
irrigated  with  a  mild  antiseptic  solution.  The  hands  of  the  operator 
should  likewise  be  sterile. 

Technic. — The  patient  is  instructed  to  empty  his  bladder  as 
completely  as  possible  while  in  the  upright  position.  He  is  then 
placed  in  the  dorsal  position.  The  catheter,  well  lubricated,  is  in- 
troduced into  the  bladder,  and  any  urine  that  remains  is  drawn  off 
into  the  graduate  and  is  measured.  This  may  amount  to  from  i 
dram  (4  c.c.)  to  several  ounces.  If  there  is  more  than  2  ounces 
(60  c.c.)  of  residual  urine,  it  is  certain  that  some  interference  with 
the  voluntary  evacuation  of  the  bladder  exists.  Observation  of  the 
flov/  of  urine  from  the  catheter  may  also  furnish  valuable  information. 
If  the  urine  is  expelled  in  a  strong  gush,  it  indicates  that  the  muscu- 
lar structure  of  the  bladder  is  competeni ,  while,  if  it  simply  escapes 
by  gravity,  an  atonic  condition  is  probably  present. 

THE  ABSORPTION  TEST 

A  test  sometimes  employed  to  determine  whether  blood  in  the 
urine  has  its  source  in  the  bladder  consists  in  injecting  a  solution  of 
iodid  of  potassium  into  the  bladder  and  later  testing  the  saliva  for 
iodin.  Ordinarily  there  will  be  no  absorption  from  the  healthy 
bladder,  but,  if  raw  or  ulcerated  surfaces  are  present,  absorption  of 
the  iodid  of  potassium  is  quite  rapid  and  iodin  will  be  eliminated  in 
the  saliva. 

Apparatus. — There  will  be  required  an  ordinary  soft-rubber  irri- 
gating catheter,  a  Janet  syringe,  and  a  test-tube. 

Asepsis. — The  usual  aseptic  precautions  employed  when  intro- 
ducing an  instrument  into  the  bladder  should  be  observed. 

Technic- — The  patient  first  empties  his  bladder.  The  soft 
catheter  is  then  introduced  and  the  bladder  is  well  irrigated  with  nor- 
mal salt  solution.  From  2  to  3  ounces  (60  to  90  c.c.)  of  a  i  per  cent, 
solution  of  potassium  iodid  are  then  injected  into  the  bladder  and  the 
catheter  is  removed.  At  the  end  of  ten  or  fifteen  minutes  some  of 
the  patient's  saliva  is  collected  in  a  test-tube  and  is  tested  for  iodin. 
This  is  readily  done  by  adding  a  few  drops  of  a  dilute  solution  of 
cooked  starch  and  stirring  with  a  glass  rod  dipped  in  fuming  nitric 
acid.     If  iodin  is  present  in  the  saliva,  the  mixture  will  turn  blue. 

CYSTOSCOPY 

Cystoscopy  is  the  inspection  of  the  interior  of  the  bladder  by  the 
aid  of  an  instrument  especially  devised  for  the  purpose,  the  cysto- 


66o  THE  BLADDER 

scope.  It  is  a  method  of  examination  that  may  be  of  the  greatest 
value  when  employed  by  an  expert,  but  it  is  of  limited  use  in  the 
hands  of  the  inexperienced,  for  it  is  absolutely  essential  that  the 
examiner  be  familiar  with  the  appearance  of  the  normal  bladder  be- 
fore he  can  recognize  and  correctly  interpret  pathological  conditions, 
and  this  can  only  be  learned  by  practical  experience. 

By  a  cystoscopic  examination  properly  carried  out  it  is  possible 
to  obtain  an  accurate  picture  of  the  interior  of  the  bladder  and  to 
study  the  appearance  of  the  ureteral  orifices  as  well  as  the  condition 
of  the  urine  that  escapes  from  them;  that  is,  whether  it  contains  pus 
or  blood.  Cystoscopy  thus  becomes  of  service  not  only  for  diagnosis 
of  obscure  vesical  affections  that  may  escape  recognition  by  other 
means,  but  also  in  the  diagnosis  between  a  possible  vesical  and  kidney 
lesion. 

The  method  has,  however,  certain  limitations.  It  cannot  be 
employed  with  success  in  the  presence  of  marked  hypertrophy  of  the 
prostate,  when  the  bladder  is  greatly  contracted,  or  when  there  is 
an  active  vesical  hemorrhage  going  on  which  obscures  the  view.  It 
is  contraindicated  in  the  presence  of  acute  urethritis,  acute  prosta- 
titis, epididymitis,  or  acute  cystitis.  The  urethra  must,  as  a  rule, 
be  of  a  caliber  of  22  to  24  French,  and,  if  the  meatus  is  narrow,  it 
must  be  first  cut,  or,  if  strictures  are  present,  they  must  be  suffi- 
ciently dilated  before  the  instrument  can  be  introduced. 

Instruments. — Cystoscopes  are  of  two  types,  the  direct  view,  in 
which  the  light  is  on  the  convex  side  of  the  beak  and  the  eye  looks 
down  a  straight  tube  through  a  window  in  the  distal  end,  and  the 
indirect  view,  in  which  the  light  is  placed  on  the  concave  side  and  the 
image  is  reflected  at  right  angles  to  the  eye-piece,  thus  giving  an 
inverted  picture.  Some  of  the  newer  indirect  view  instruments, 
however,  give  an  upright  picture. 

For  the  simple  examination  of  the  bladder  the  use  of  an  indirect 
view  cystoscope  gives  the  best  results,  as  with  such  an  instrument  the 
roof,  floor,  and  walls  of  the  bladder — excepting  a  part  of  the  posterior 
wall — may  be  readily  inspected.  The  examination  may  be  satisfac- 
torily performed  either  by  means  of  a  special  exploring  cystoscope, 
such  as  the  Nitze,  Otis,  Schapira,  etc.,  or  by  means  of  one  of  the 
ureter-catheterizing  cystoscopes  to  be  described  later  on  (see  page 
705).  The  exploring  cystoscope  has  an  advantage  over  the  cathe- 
terizing  instruments,  however,  in  that  its  shaft  being  small  the  exam- 
ination is  less  painful. 

The  Nitze  instrument  (Fig.  684)  is  the  oldest  type  of  the  indirect 


CYSTOSCOPY 


66l 


or  right-angled  view  cystoscope.  It  consists  essentially  of  a  metal 
tube  9  inches  (23  cm.)  long  and  from  15  to  24  French  scale  in  size, 
having  at  the  distal  end  a  short  beak  fitted  with  a  small  electric  lamp 
and  on  the  concave  side  of  the  instrument  at  the  point  where  the  beak 
joins  the  shaft  a  lens,  beneath  which  is  placed  a  prism.  From  the 
prism  the  image  is  reflected  at  right  angles  through  a  series  of  lenses 
to  the  eye-piece.  A  small  knob  soldered  on  the  circumference  of  the 
eye-piece  indicates  the  position  of  the  cystoscopic  window.  The 
instrument  is  fitted  with  two-way  stopcocks  for  irrigation  should  the 
lens  become  cloudy.  Space  does  not  permit  a  description  of  the 
many  modifications  of  the  Nitze  instrument,  each  of  which  has  ad- 
vantages of  its  ovm. 

The  illumination  for  cystoscopes  may  be  furnished  from  a  six- 
er eight-cell  battery  or  from  the  street  current  provided  a  controller  is 
employed. 


Fig.  684. — Nitze's  cystoscopes. 


Additional  instruments  required  are  a  Janet  syringe,  holding 
from  3  to  4  ounces  (90  to  120  c.c),  or  an  irrigating  jar,  and  a  catheter. 

Asepsis. — Formalin  vapor  may  be  employed  or  the  instrument 
may  be  immersed  in  a  i  to  20  carboHc  acid  solution  for  ten  minutes 
followed  by  rinsing  in  alcohol  and  then  sterile  water.  The  external 
genitals  should  be  cleaned  with  soap  and  water  followed  by  a  i  to 
5000  bichlorid  solution.  The  examiner's  hands  are  to  be  likewise 
steriHzed. 

Position  of  the  Patient. — The  examination  is  performed  with  the 
patient  in  the  Hthotomy  position  and  with  his  buttocks  close  to  the 
edge  of  the  table  or,  as  preferred  by  some  operators,  in  the  semi- . 
recumbent  posture.  The  best  form  of  table  to  use  is  one  pro\^ded 
with  uprights  which  are  surmounted  with  double  inchned  rests  about 
15  inches  (37  cm.)  above  the  level  of  the  table  for  the  support  of  the 
patient's  thighs  and  knees  (Fig.  685).     It  is  a  great  convenience  to 


662 


THE  BLADDER 


have  a  table  provided  with  a  wheel  within  reach  of  the  operator,  by 
turning  which  it  may  be  raised  or  lowered  at  will. 

Anesthesia, — Local  anesthesia  of  the  urethra  is  generally  neces- 
sary, though  in  exceptional  cases  cystoscopy  may  be  performed  with- 
out anesthesia.  The  instillation  into  the  deep  urethra  of  a  few  drops 
of  a  2  per  cent,  solution  of  cocain  may  be  sufficient.  A  sensitive 
bladder  may  be  rendered  anesthetic  by  first  emptying  it  and  then 
filling  it  with  5  ounces  (150  c.c.)  of  a  warm  o.i  per  cent,  solution  of 
cocain  to  which  is  added  20  drops  (1.25  c.c.)  of  adrenalin  and  having 


Fig.  685. — Table  with  Bierhofl's  leg  supports  for  cystoscopy.     (Greene  and 

Brooks.) 

the  whole  amount  retained  for  fifteen  to  twenty  minutes.  Guyon's 
method  of  obtaining  local  anesthesia  consists  in  injecting  into  the 
rectum  three-quarters  of  an  hour  beforehand  a  mixture  containing: 


Antipyrin, 

Laudanum, 

Water, 


gr.  xiv  (0.9  gm.) 
TTlx  (0.6  c.c.) 
5iii  (90  c.c.) 


In  some  adult  cases,  where  the  urethra,  bladder,  or  prostate  are 
extremely  sensitive,  and  in  children  general  anesthesia  may  be 
required. 

Preparations. — The  bladder  should  first  be  emptied  and  should 
then  be  thoroughly  irrigated  with  a  saturated  solution  of  boric  acid 
by  means  of  a  catheter  and  Janet  syringe  until  the  fluid  returns  clear, 
as  a  satisfactory  examination  can  be  made  only  in  a  clean  bladder.     If 


CYSTOSCOPY 


663 


an  irrigating  cystoscope  is  employed,  the  irrigation  may  be  performed 
through  the  sheath  of  the  instrument.  Four  to  6  ounces  (120  to 
180  c.c.)  of  a  saturated  solution  of  boric  acid  or  normal  salt  solution 
are  then  injected  into  the  bladder  and  allowed  to  remain  so  as  to 
smooth  out  the  folds  of  mucous  membrane  and  furnish  space  for  the 
cystoscope  to  be  moved  about. 

If  there  is  sufficient  bleeding  from  the  bladder  to  interfere  with 
the  examination,  a  solution  of  i  to  3000  adrenahn  chlorid  may  be 
injected  through  the  catheter  and  allowed  to  remain  for  about  ten  or 
fifteen  minutes,  when  it  is  drawn  off  and  the  bladder  is  distended. 


Pig.  686. — Position  of  the  cystoscope  for  inspection  of  the  roof  of  the  bladder. 

Everything  that  will  be  required  during  the  examination  should 
be  placed  near  at  hand,  and  the  cystoscope  light  should  be  tested 
under  water  before  the  instrument  is  introduced. 

Technic. — The  instrument  after  being  thoroughly  tested,  is  lubri- 
cated with  glycerin  or  lubrichondrin  and  is  gently  passed  into 
the  bladder  in  the  same  manner  one  would  pass  a  sound.  Great  care 
should  be  taken  not  to  use  any  force  in  introducing  the  instrument. 
If  there  is  any  difficulty  in  making  the  beak  enter  the  opening  in  the 
triangular  ligament,  pressure  applied  on  the  perineum  by  the  fingers 
of  the  free  hand  will  assist  in  its  passage  into  the  membranous  urethra 
(see  Fig.  608).  As  soon  as  the  instrument  has  entered  the  bladder,  it 
can  be  freely  moved  about. 

The  operator  then  takes  his  seat  with  his  eyes  on  a  level  with  the 
ocular  end  of  the  instrument,  the  light  is  turned  on,  and  the  interior  of 


664 


THE  BLADDER 


the  bladder  is  systematically  inspected,  care  being  taken  not  to  touch 
the  mucous  membrane  with  the  light.  It  should  be  remembered  that 
in  using  a  prism  form  of  indirect  view  cystoscope  the  image  will  be 
reversed,  as  in  the  laryngoscope.  The  instrument  being  introduced 
with  its  beak  turned  up,  the  roof  of  the  bladder  will  first  come  into 
view  (Fig.  686).  In  order  to  see  as  much  of  this  portion  of  the  blad- 
der as  possible,  the  instrument  should  be  rotated  first  in  one  direction 
and  then  in  the  other  and  then  pushed  farther  in,  repeating  these 
movements  until  the  entire  roof  has  been  inspected.  By  depressing 
or  elevating  the  shaft  a  more  complete  view  of  the  anterior  or  poste- 
rior wall  is  obtained.  The  beak  of  the  instrument  is  then  rotated  so 
that  it  faces  toward  the  floor  of  the  bladder  (Fig.  687),  and  the  instru- 
ment is  withdrawn  until  the  prostate  appears  as  a  clear  dark  red  cres- 
cent.    If  hypertrophied,  it  will  appear  deformed  in  the  picture,  and 


Fig.  687. — Position  of  the  cystoscope  for  inspection  of  the  floor  of  the  bladder. 


the  degree  of  its  enlargement  and  its  location  may  be  recognized. 
The  instrument  is  next  pushed  slowly  backward  in  the  median  line 
as  far  as  the  fundus,  the  examiner  carefully  inspecting  the  floor  of  the 
bladder  as  the  instrument  is  advanced.  By  slightly  rotating  the 
instrument  first  to  one  side  and  then  to  the  other  a  large  extent  of  the 
floor  may  be  viewed. 

The  mucous  membrane  normally  has  a  salmon  or  grayish-pink 
tint  and  is  smooth  and  glossy  with  the  superficial  vessels  standing 
out  here  and  there.  When  acutely  inflamed,  it  becomes  a  dark  red 
color  and  has  a  velvety  appearance  and  there  is  a  general  hyperemia 
so  that  the  smafl  blood-vessels  disappear.  In  chronic  inflammation 
the  mucous  membrane  may  take  on  a  grayish   tint  and  the  folds 


CYSTOSCOPY    IN    THE    FEilALE  665 

appear  much  thickened.     This  region  should  be  carefully  examined 
for  small  stone,  tubercular  ulcers,  and  new  growths. 

Having  inspected  the  floor,  the  instrument  is  turned  45  degrees  to 
one  side  and  is  gradually  withdra^^^l  from  the  fundus.  In  this  way 
the  opening  of  the  ureter  on  that  side  will  come  to  view  as  an  oblique 
slit  or  as  a  small  dimple  (Fig.  688)  in  a  prominent  papilla,  and,  if  it  is 
watched,  it  will  be  seen  to  emit  a  gush  of  urine  every  ten  to  fifteen 
seconds.  If  not  immediately  found,  the  interureteric  line,  which  runs 
transversely  across  the  central  field  between  the  two  ureters,  should 
be  identified  and,  by  tracing  this  to  one  side  or  the  other,  the  ureteral 
orifice  may  be  located.  The  appearance  of  the  ureteral  orifice  should 
be  carefully  inspected  for  signs  of  ulceration,  erosions,  or  inflammation 
which  might  indicate  a  diseased  kidney  on  that  side,  and  likewise  the 
character  of  the  urine  which  escapes  should  be  noted,  i.e.,  whether 
clear,  purulent,  or  bloody. 


Fig.  688. — Appearance  of  the  ureteral  orifices. 

The  lateral  wall  is  carefully  inspected  as  far  as  the  vesical  neck. 
The  instrument  is  then  rotated  90  degrees  to  obtain  a  view  of  the 
opposite  side  and  it,  including  the  ureter  of  that  side,  are  examined 
while  the  instrument  is  slowly  passed  to  the  fundus  again.  Follow- 
ing some  such  scheme,  the  entire  bladder  may  be  inspected  except 
a  portion  of  the  posterior  wall  which  is  invisible  with  an  indirect  view 
instrument.  During  the  examination  it  is  well  to  shut  oft"  the  fight 
at  intervals  so  as  to  allow  the  instrument  to  cool. 

At  the  end  of  the  examination  the  Hght  is  turned  oft"  and  the  instru- 
ment is  carefully  withdrawm,  taking  care  to  see  that  the  beak  is  again 
turned  up  before  this  is  done.  The  patient's  bladder  is  then 
emptied  and  irrigated  with  boric  acid  solution. 

CYSTOSCOPY  IN  THE  FEMALE 

The  examination  of  the  female  bladder  may  be  performed  by 
using  an  ordinary  male  cystoscope  or  a  somewhat  shorter  female 


666 


THE   BLADDER 


instrument.  Such  examination,  which  is  less  difficult  than  in  the 
male  on  account  of  the  short  length  of  the  urethra,  requires  no  separate 
description,  as  the  technic  differs  in  no  essential  way  from  the  method 


Fig.  689. — Instruments  for  cystoscopy  in  the  female,  i,  Electric-lighted 
open-tube  cystoscope;  2,  urethral  dilator;  3,  urine  evacuator;  4,  alligator- jawed 
forceps;  5,  ureteral  searcher. 


Fig.  690. — Kelly's  open-tube  cystoscope. 


used  in  the  male.  Another  method  of  vesical  inspection  is  by  means 
of  Kelly's  open  straight  tubes  and  atmospheric  distention  of  the 
bladder. 

Instruments. — For  cystoscopy  according  to  Kelly's  method  there 
will  be  required:  Kelly's  specula,  or  some  of  their  modifications, 
an  electric  head  light  or  head  mirror,  a  Kelly  dilator  to  stretch  the 


CYSTOSCOPY    IX    THE    FEiLA.LE 


667 


external  urethral  orilice,  a  urine  evacuator  to  draw  off  residual  urine, 
alligator  forceps  for  holding  cotton  swabs,  and  a  ureteral  probe  for 
probing  the  mucous  membrane  or  locating  the  ureteral  orifices 
(Fig.  689). 

The  specula  consist  of  cylindrical  tubes  3  1/5  inches  (8  cm.)  long, 
of  equal  length  throughout,  and  in  sizes  of  from  1/5  inch  (^5  mm.) 
in  diameter  up  to  4/5  inch  (20  mm.).  Those  below  Xo.  12  are  gen- 
erally employed  for  diagnostic  purposes.  The  tubes  are  of  German 
silver  or  nickel-plated,  each  having  a  conical  expansion  at  the  ocular 
end  to  which  is  fastened  a  strong  handle  (Fig.  690).  Each  tube  is 
supplied  with  an  obturator  having  a  conical  end-piece.     The  illumina- 


FiG.  691. — Enlarged  view  of  an  electric-lighted  open-tube  cystoscope. 


tion  is  furnished  by  reflected  light  or  from  an  electric  head  light,  the 
latter  being  preferable.  These  specula,  however,  may  be  obtained 
furnished  with  an  electric  Hght  at  the  distal  end^  (Fig.  691),  an  instru- 
ment which  simplifles  the  operation  for  one  not  accustomed  to  the  use 
of  a  head  light. 

The  urethral  dilator  is  a  cone-shaped  metallic  instrument  which 
gradually  increases  in  size  from  the  point  until  at  the  base  it  measures 
16/25  inch  (16  mm.)  in  diameter.  The  instrument  is  graduated 
so  that  the  examiner  can  determine  the  required  amount  of  dilatation. 

The  urine  evacuator  is  necessary  for  the  purpose  of  removing  the 

^They  are  made  by  the  Electro-Surgical  Instrument  Company  of  Rochester, 
New  York. 


668 


THE   BLADDER 


urine  that  collects  in  the  floor  of  the  bladder  which  would  otherwise 
interfere  with  the  examination.  It  consists  of  a  suction  bulb  attached 
by  means  of  a  long  delicate  rubber  tube  to  a  small  perforated  glass 
bulb.  In  the  Luys'  open  tube  cystoscope  an  aspirating  tube  is  incor- 
porated in  the  instrument. 

Asepsis. — All  the  instruments  with  the  exception  of  the  light  car- 
rier may  be  boiled  for  five  minutes  in  a  i  per  cent,  soda  solution. 
The  latter  may  be  sterilized  by  immersion  in  a  i  to  20  carbolic  acid 
solution  followed  by  rinsing  in  sterile  water.     The  operator's  hands 


Fig.  692. — Method  of  dilating  the  itrethra.     (Ashton.) 

should  be  carefully  sterilized  and  the  external  genitals  and  mouth 
of  the  urethra  should  be  cleansed  with  soap  and  water,  followed  by 
a  I  to  5000  solution  of  bichlorid  of  mercury. 

Position  of  Patient. — Two  positions  are  employed,  the  dorsal  and 
the  knee-chest.  In  the  dorsal  position  the  patient  lies  with  the  head 
and  thorax  resting  on  the  table  and  the  hips  elevated  8  to  12  inches 
(20  to  30  cm.)  upon  cushions  so  as  to  raise  the  pelvis  and  permit  the 
bladder  to  distend  with  air  when  the  cystoscope  is  introduced.  While 
the  dorsal  posture  is  the  least  wearing  on  the  patient,  it  is  not  suited 
for  stout  persons.  In  such  cases,  the  knee-chest  posture,  with  the 
knees  separated  10  or  12  inches  (25  or  30  cm.),  is  more  suitable. 

Preparations  of  Patient. — Before  the  patient  is  placed  upon  the 
table  the  rectum  and  bladder  should  be  emptied. 

Anesthesia. — ^Local  anesthesia  is  generally  sufficient  except  in 
very  nervous  women.     A  pledget  of  cotton  saturated  with  a  2  per 


CYSTOSCOPY    IX    THE    TEilALE 


cent,  solution  of  cocain  introduced  upon  an  applicator  within  the 
meatus  and  alloAved  to  remain  for  five  minutes  will  anesthetize  the 
urethra  sufficiently  to  allow  it  to  be  dilated. 

Technic. — As  a  rule,  it  is  first  necessary  to  dilate  the  urethral 


Fig.  693. — ^.lethod  of  holding  the  open-tube  cystoscope  during  its  introduction 

into  the  bladder. 

orifice;  the  rest  of  the  canal,  being  very  dilatable,  is  easily  stretched 
by  the  cystoscope  in  its  passage.  The  dilator  is  lubricated  with  one 
of  the  Irish-moss  preparations  and  is  introduced  into  the  urethra  with 
a  slight  boring  motion  until  the  required  amount  of  dilatation  is 


Fig.  694. — Inspection  of  the  female  bladder  through  an  open-tube  cystoscope. 

reached  (Fig.  692).  Dilatation  to  about  X0.12  on  the  dilator  is 
generally  sufficient.  A  speculum  of  a  size  from  7  to  10,  depending 
upon  the  age  of  the  patient,  is  then  selected.  It  should  be  grasped  in 
the  operator's  right  hand,  the  cylinder  lying  between  the  index  and 


670 


THE   BLADDER 


middle  fingers,  with  the  thumb  against  the  obturator,  as  shown  in 
Fig.  693.  With  the  fingers  of  the  left  hand  the  labia  are  separated 
and  the  speculum,  well  lubricated,  is  introduced  through  the  urethral 
orifice,  whence  it  is  gradually  pushed  into  the  bladder  following  the 
urethral  curve  under  the  pubic  arch.  Upon  removal  of  the  obturator, 
air  rushes  in  distending  the  bladder.  If,  when  the  patient  is  in 
the   knee-chest   position,    the   bladder   does    not  balloon   up,    two 


Fig.  695. — -Method  of  removing  residual  urine  during  a  cystoscopic 


examination. 


fingers  may  be  introduced  into  the  vagina  so  as  to  distend  it  with 
air.  The  illumination  is  then  turned  on,  or,  in  the  absence  of  a  self- 
illuminated  speculum,  the  light  from  the  electric  head  light  or  head 
mirror  is  thrown  into  the  bladder  through  the  speculum,  and  the 
bladder  is  systematically  examined  (Fig.  694). 

By  alternately  moving  the  speculum  from  side  to  side  and  depress- 
ing or  elevating  the  handle  all  portions  of  the  bladder  may  be 
inspected.  If  the  patient  is  in  the  dorsal  posture,  urine  soon  collects 
in  a  pool  on  the  base  of  the  bladder,  and  this  must  be  removed  as 
often  as  required  by  means  of  the  evacuator  (Fig.  695).  By  means  of 
the  cotton  mops  held  in  the  alHgator  forceps,  mucus,  blood,  or  pus 
that  may  obscure  a  clean  view  of  the  mucous  membrane  may  be 
wiped  away. 


IRRIGATIONS  67 1 

SKIAGRAPHY 

The  X-rays  are  sometimes  used  in  locating  a  vesical  stone  which, 
from  being  buried  in  a  pocket  or  being  situated  behind  the  prostate, 
may  escape  detection  by  other  means.  The  success  of  the  skiagraph 
depends  to  a  large  extent  upon  the  composition  of  the  calculus.  Oxa- 
late and  phosphate  stones  cast  a  dense  shadow,  but  those  composed 
of  urates  and  uric  acid  cast  very  faint  shadows,  and  so  may  be 
missed  entirely.  The  bony  walls  of  the  pelvis  may  likewise  interfere 
and  give  a  negative  result.  To  secure  a  satisfactory  radiograph  it 
is  essential  that  the  bowels  be  emptied  by  a  purge  administered  the 
night  before  followed  by  an  enema  in  the  morning. 

By  injecting  into  the  bladder  a  solution  of  bismuth  or  one  of  the 
silver  salts  and  taking  a  radiograph  immediately,  much  valuable 
information  as  to  the  size  and  position  of  the  bladder  and  the  presence 
or  absence  of  diverticula,  sacculations,  tumors,  or  obstruction  at  the 
vesical  neck  may  be  obtained. 

Bismuth  is  used  in  a  loper  cent,  watery  solution.  Of  the  silver 
salts,  collargol  in  2  to  lo  per  cent,  solution  and  argyrol  in  25  per  cent, 
solution  are  generally  employed.  Eight  ounces  (250  c.c.)  of  solu- 
tion will  be  sufficient. 

Therapeutic  Measures 
IRRIGATIONS 

Irrigation  of  the  bladder  maybe  employed  either  for  simple  cleans- 
ing purposes,  as  is  required  in  preparation  for  an  instrumental 
examination  or  operative  procedure,  or  to  produce  a  local  effect  upon 
the  mucous  membrane.  Irrigations  are  thus  of  the  greatest  value  in 
the  treatment  of  various  inflammatory  affections  of  the  bladder.  In 
acute  cystitis,  however,  on  account  of  the  distention  produced,  they 
often  increase  the  pain  and  may  aggravate  the  trouble.  They  should 
be  employed,  however,  in  acute  cases  if  the  bladder  does  not  com- 
pletely empty  itself  and  there  is  decomposition  of  urine.  Irrigations 
are  also  contralndicated  where  the  bladder  cannot  hold  more  than  i 
ounce  (30  c.c.)  of  fluid  without  exciting  a  desire  to  urinate;  in  such 
cases,  instiUations  should  be  substituted. 

There  are  two  methods  of  performing  vesical  irrigation;  (i)  by 
injecting  the  fluid  in  sufficient  quantity  to  distend  the  bladder  and 
having  it  retained  a  short  time  before  allowing  it  to  escape,  and  (2) 
by  using  a  double-flow  catheter  which  allows  the  fluid  to  escape  as  fast 


672 


THE   BLADDER 


as  it  flows  ill.  In  the  majority  of  cases  the  former  is  the  preferable 
method  as  a  certain  amount  of  distention  of  the  bladder  is  necessary 
in  order  to  wash  out  pus,  bacteria,  and  debris  from  the  folds  of  mucous 
membrane. 

Apparatus. — A  large  glass  funnel,  4  feet  (120  cm.)  of  rubber 
tubing,  a  soft-rubber  catheter,  a  large  glass  graduate,  a  thermometer, 
and  a  waste-pail  are  required  (Fig.  696). 

A  double-flow  soft  catheter  (Fig.  697)  may  be  employed  in  place  of 
the  ordinary  catheter  if  desired.  When  this  is  used  a  graduated  glass 
irrigating  jar  should  take  the  place  of  the  funnel. 


Fig.  696. — Apparatus  for  bladder  irrigations. 


Asepsis. — The  apparatus  is  boiled  and  the  thermometer  sterilized 
by  immersion  for  10  minutes  in  a  i  to  500  bichlorid  of  mercury  solu- 
tion followed  by  a  thorough  rinsing  in  sterile  water.  The  operator's 
hands  should  be  thoroughly  scrubbed. 

Solutions  Used. — Normal  salt  solution  (oi  (4  gm.)  of  salt  to  the 
pint  (500  c.c.)  of  water),  a  saturated  solution  of  boric  acid,  silver 
nitrate  i  to  15,000  to  i  to  5000,  potassium  permanganate  i  to  8000  to 
I  to  4000,  bichlorid  of  mercury  i  to  100,000  to  i  to  5000,  formalin 
I  to  5000,  oxycyanid  of  mercury  i  to  5000  to  i  to  2000,  carbolic  acid, 
etc.,  are  among  the  numerous  agents  employed. 

It  is  always  well  to  begin  the  treatment  with  the  weaker  solutions 
and  gradually  increase  the  strength  as  indicated.  After  an  irrigation 
with  a  poisonous  drug,  the  bladder  should  be  douched  with  normal 
salt  solution  to  prevent  absorption. 

Temperature. — The  irrigating  fluid  should  be  at  a  temperature  of 
100°  to  105°  F.  (38°  to  41°  C). 


IRRIGATIONS 


673 


Quantity. — The  irrigations  should  be  continued  until  the  fluid 
returns  clear.  As  a  rule  about  i  pint  (500  c.c.)  of  solution  will  be 
suflScient. 


Fig.  697. — Return-flow  soft-rubber  catheter. 


Fig.  698. — Irrigation  of  the  bladder  by  the  single-catheter  method. 

Frequency. — When  there  is  profuse  suppuration  and  rapid  decom- 
position of  urine,  the  irrigations  are  employed  twice  a  day.  In  a 
mild  case  daily  irrigations  or  on  alternate  days  will  sufl&ce.  A  lapse  of 
one  or  two  days,  however,  should  intervene  when  very  strong  solu- 
tions are  employed. 
43 


674  THE   BLADDER 

Position  of  Patient.— The  patient  should  be  in  the  dorsal  position. 

Preparation  of  Patient.— The  bladder  should  be  empty.  The 
external  genitals  are  washed  with  soap  and  water  followed  by  a  i  to 
5000  bichlorid  of  mercury  solution,  and  the  urethra  is  irrigated  with  a 
boric  acid  or  i  to  5000  potassium  permanganate  solution. 

Technic.  i.  Single  Catheter  Method. — The  catheter,  well  lubri- 
cated, is  gently  passed  into  the  bladder,  and  any  residual  urine  is 


Fig.  699. — Irrigation  of  the  bladder  with  a  double-flow  catheter. 

allowed  to  escape.  The  funnel  is  filled  with  from  3  to  6  ounces  (90 
to  180  c.c.)  of  the  solution,  and  the  tubing  leading  from  the  funnel  is 
attached  to  the  catheter,  first  taking  care  to  see  that  air  or  any  cold 
solution  is  expelled  from  the  tube.  The  funnel  is  then  raised  2  or  3 
feet  (60  to  90  cm.)  above  the  patient  and  the  solution  is  permitted  to 
slowly  flow  mto  and  distend  the  bladder.  As  soon  as  the  patient 
complains  of  the  distention,  the  flow  is  shut  off.  After  allowing  the 
solution  to  remain  in  the  bladder  a  few  moments,  the  funnel  is  lowered 
below  the  level  of  the  bladder  and  the  fluid  is  allowed  to  escape  into 


AUTO-IRRIGATIONS  675 

the  waste-pail  (Fig.  698).  The  funnel  is  then  refilled  and  the  process 
repeated  until  the  fluid  returns  clear. 

In  performing  the  irrigation  care  must  be  observed  not  to  overdis- 
tend  the  bladder.  Just  how  much  can  be  injected  at  a  time  depends 
upon  the  individual  case,  but  it  should  not  be  sufficient  to  cause  any 
pain.  Entrance  of  air  into  the  bladder  should  also  be  guarded 
against. 

2.  Double- fl'Oiv  Catheter  Method. — The  technic  varies  a  little  from 
that  just  described.  The  catheter  is  passed  into  the  bladder  and  the 
irrigating  tubing  is  attached  to  the  inflow  tube  of  the  catheter.  The 
reservoir,  filled  mth  the  entire  amount  of  fluid  to  be  used  during  the 
irrigation,  is  then  raised  2  to  3  feet  (60  to  90  cm.)  above  the  bladder 
and  the  solution  is  allowed  to  flow.  As  fast  as  it  enters  the  bladder,  it 
is  carried  off  again  through  the  outflow  tube  (Fig.  699);  but,  by 
occasionally  compressing  the  outflow  tube,  the  bladder  may  be  more 
or  less  completely  filled  before  the  fluid  is  permitted  to  escape.' 

AUTO -IRRIGATIONS 

While  it  is  not  advisable  to  allow  a  patient  to  irrigate  his  own 
bladder  in  the  presence  of  a  severe  cystitis,  auto-irrigation  may  be 
safely  performed  for  the  purpose  of  keeping  the  bladder  clean  by  those 
who  are  compelled  to  lead  a  catheter  Hfe.  The  patient  should,  how- 
ever, be  carefully  instructed  how  to  sterilize  the  catheter,  his  hands, 
etc.,  and  in  the  proper  method  of  performing  the  irrigation,  and  he 
should  be  fully  warned  of  the  dangers  of  neglecting  to  follow  the  strict- 
est rules  of  cleanhness. 

Apparatus. — A  douche  bag  with  a  capacity  of  i  quart  (i  liter),  4 
feet  (120  cm.)  of  rubber  tubing,  a  T-shaped  glass  tube,  a  soft-rubber 
catheter,  and  a  waste-pail  comprise  the  necessary  outfit.  The 
T-shaped  glass  connection  is  placed  between  the  catheter  and  the 
tubing  of  the  reservoir  and  to  its  long  arm  is  attached  another  piece 
of  tubing  that  leads  to  the  waste-pail.  A  shut-ofl'  chp  is  placed  on  the 
tube  leading  from  the  irrigator  and  another  upon  the  waste  tube 
(Fig.  700). 

Solution  Used. — It  is  better  not  to  entrust  the  patient  vnih  strong 
antisepric  solutions;  instead  a  saturated  (4  per  cent.)  solution  of  boric 
acid  should  be  used.  It  is  prepared  by  dissolving  about  5  teaspoon- 
fuls  (20  gm.)  of  boric  acid  crystals  in  i  pint  (500  c.c.)  of  hot  water. 

Position  of  Patient. — The  irrigation  is  most  conveniently  given 
with  the  patient  sitting  in  a  chair  and  with  the  waste-pail  on  the  floor 
between  the  legs. 


676 


THE  BLADDER 


Technic. — The  reservoir  is  filled  with  i  pint  (500  c.c.)  of  warm 
(105°  F.  (41°  C.))  boric  acid  solution  and  is  hung  on  a  hook  about  3 
feet  (90  cm.)  above  the  level  of  the  bladder.  The  patient  then  intro- 
duces his  catheter  into  the  bladder  and  draws  off  the  urine.  The 
solution  is  allowed  to  flow  from  the  tubing  to  expel  any  air  or  cold 
fluid,  and  the  tubing  is  then  connected  with  the  catheter.  The 
solution  is  allowed  to  flow  into  the  bladder  until  there  is  a  feeling  of 
distention,  when  the  flow  is  shut  off  and  the  outflow  pipe  is  opened 


Fig.   700. — Apparatus  for  auto-irrigation  of  the  bladder. 

allowing  the  fluid  to  escape  into  the  waste-pail.     The  process   is 
repeated  until  the  reservoir  is  emptied. 


INSTILLATIONS 

Instillations  dift"er  from  irrigations  in  that  a  smaller  quantity  of 
solution  is  used  and  the  fluid  is  allowed  to  remain  in  the  bladder. 
Stronger  solutions  can  thus  be  employed  and  it  is  possible  to  obtain  a 
more  lasting  effect  upon  the  mucous  membrane  than  from  an  irriga- 
tion. Instillations  are  very  useful  in  all  cases  of  cystitis,  but  espe- 
cially those  in  which  the  inflammation  is  particularly  severe  about  the 
trigone  and  vesical  neck. 

The  immediate  effect  of  the  instillation  is  to  induce  a  moderate 
congestion  accompanied  by  an  increased  desire  to  urinate  and  some 
pain,  but  this  soon  passes  off  and  is  followed  by  reaction  and  a  gradual 
relief  of  the  symptoms. 

Syringe. — A  Keyes-Ultzmann  syringe  will  be  required  (Fig.  701). 
When,  however,  it  is  desired  to  inject  more  than  1/2  dram  (2  c.c.) 


INSTILLATIONS 


677 


of  solution,  a  soft-rubber  catheter  and  glass  syriDge  of  the  desired 
capacity  should  be  substituted  for  the  above. 

Solutions  Used. — Silver  nitrate  beginning  with  a  i  to  1500  solu- 
tion increased  to  5  per  cent.,  protargol  i  to  20  per  cent.,  bichlorid  of 
mercury  i  to  10,000  to  i  to  5,000,  a  10  per  cent,  emulsion  of  iodoform 
and  glycerin,  etc.,  are  often  employed. 

Quantity. — As  a  rule  about  15  to  30  HI  (i  to  2  c.c.)  are  injected, 
but  when  it  is  desired  to  medicate  a  large  surface,  as  much  as  i  dram 
(4  c.c.)  or  more  may  be  used. 

Frequency. — Instillations  may  be  employed  every  other  day  to 
every  third  or  fourth  day  according  to  the  reaction  they  provoke. 

Position  of  Patient. — The  dorsal  position  is  used. 

Preparations  of  Patient. — The  bladder  should  be  empty,  and  if 
there  is  residual  urine  it  should  be  drawn  off  by  a  catheter.  The 
external  genitals  are  cleansed  and  the  urethra  is  irrigated  with  a 
boric  acid  solution. 

Technic. — The  syringe  is  first  filled  with  the  desired  amount  of 
solution.     The  nozzle,  after  being  well  lubricated  with  lubrichondrin , 


Fig.   701. — Keyes-Ultzmann  instillation  syringe. 

is  then  introduced  in  the  same  manner  employed  in  passing  any 
curved  urethral  instrument  (see  page  587)  until  its  point  Hes  in  the 
prostatic  urethra.  This  will  be  when  the  shaft  of  the  instrument  has 
been  depressed  between  the  legs  to  an  angle  of  a  little  less  than  45 
degrees  with  the  horizon.  The  required  amount  of  medication  is 
then  slowly  injected  into  the  prostatic  urethra,  whence  it  flows  over 
the  vesical  neck  and  trigone.  In  removing  the  syringe  the  piston 
should  be  first  withdrawn  a  little  so  as  to  prevent  any  solution  leaking 
from  it  along  the  urethra. 

When  using  the  catheter  method  of  instillation,  the  same  technic 
as  for  a  posterior  urethral  irrigation  (page  614)  is  followed. 


CYSTOSCOPIC  TREATMENT 

In  the  hands  of  an  expert  the  cystoscope  becomes  an  instrument 
of  great  value  in  treating  vesical  lesions.     While  cystoscopic  treat- 


6/8 


THE  BLADDER 


ment  is  more  difficult  in  the  male  than  in  the  female,  such  procedures 
as  removing  small  calculi  and  foreign  bodies,  dilating  the  ureteral 
openings,  snaring  small  growths,  the  curettage  of  ulcers,  the  direct 
application  of  strong  solutions  of  silver  nitrate  to  diseased  areas  by- 
means  of  a  cotton- tipped  probe,  etc.,  may  be  satisfactorily  per- 
formed, even  in  the  male,  by  a  physician  of  skill  and  experience. 

Instruments. — For  male  cases,  a  direct-view-air-distention  cysto- 
scope  provided  with  a  perforated  window  and  bulb-aspirator  (Fig. 
702)  is  necessary.  In  the  female,  Kelly's  tubes  (page  666)  or  some 
of  their  modifications  are  employed. 


^-^^ 


Fig.  702. — Bransford  Lewis  operating  cystoscope.     (Lewis  in  Keen's  Surgery.) 

Technic. — The  method  of  exposing  and  treating  diseased  areas  is 
performed  in  the  same  manner  in  which  the  bladder  is  inspected 
(pages  663,  669)  and  requires  no  further  description  here.  In 
making  applications  of  strong  solutions,  however,  care  should  be 
taken  to  bring  the  solution  only  in  contact  with  the  diseased  area  and 
not  to  saturate  the  applicator  with  an  excess  of  solution. 


THE  DESTRUCTION  OF  VESICAL  GROWTHS  BY 
THE  HIGH  FREQUENCY  CURRENT 

While  the  use  of  the  high  frequency  (Oudin)  current  for  the 
destruction  of  neoplasms  has  been  employed  for  a  number  of  years 
in  the  treal  ment  of  superficial  and  cutaneous  growths,  the  adaptation 
of  this  method  of  treatment  to  the  destruction  of  vesical  papillomata 
is  of  comparatively  recent  date.  Beer  of  Xew  York  in  19 10  being  the 


DESTRUCTION   OF  VESICAL   GROWTHS  679 

first  to  suggest  it.  Since  then  Keyes,  Jr.,  and  others  have  reported 
upon  the  use  of  this  form  of  treatment  in  vesical  growths,  both 
benign,  and  mahgnant,  and  in  the  benign  papillomata  the  results 
have  been  uniformly  successful.  Against  malignant  growths,  how- 
ever, unless  very  small,  the  high  frequency  current  has  not  proved 
more  than  a  palliative  measure. 

Briefly  the  method  of  treatment  consists  in  the  repeated  applica- 
tion of  the  high  frequency  current  to  the  tumor  by  means  of  an  insul- 
ated wire  introduced  into  the  growth  through  the  aid  of  a  cystoscope. 
The  current  produces  an  intense  reaction  in  the  tissues  to  which  it 
is  applied  followed  by  necrosis  and  the  gradual  sloughing  away  of  the 
growth. 

Properly  applied  the  treatments  are  practically  painless  unless 
the  electrode  comes  in  contact  with  the  bladder  wall. 

Apparatus. — An  ordinary  direct  or  indirect  ureter  catherizing 
cystoscope  (see  page  705),  a  Janet  syringe,  a  catheter,  a  heavily 
insulated  6-ply  copper  wire  cable  to  fit  into  the  catheter  chamber  of 
the  cystoscope,  and  a  high  frequency  machine  with  a  Oudin  resonator 
are  required. 

Asepsis. — The  same  as  for  a  cystoscopic  examination  (see  page 
661). 

Position  of  Patient. — The  same  as  for  a  cystoscopic  examination 
(see  page  661). 

Anesthesia. — General  anesthesia  is  not  required.  The  methods 
of  obtaining  local  anesthesia  have  been  fully  described  (see 
page  662). 

Strength  of  Current. — The  spark  gap  should  be  1/8  to  1/4  of  an 
inch  (3  to  6  mm.).  A  wider  gap  gives  greater  voltage  and  produces 
too  strong  a  reaction. 

Duration  of  Each  Treatment. — The  current  is  appHed  to  one  spot 
for  from  15  to  30  seconds  at  a  time,  and  the  number  of  applications 
will  depend  upon  the  size  of  the  growth.  Each  treatment  should  not 
average  more  than  from  3  to  5  minutes. 

Frequency  of  Treatments. — Ordinarily  treatments  are  given  at 
intervals  of  from  4  to  7  days.  In  very  sensitive  bladders  an  interval 
of  from  10  days  to  2  weeks  may  elapse  between  treatments. 

Preparations  of  the  Patient. — The  external  genitals  are  cleansed 
with  soap  and  water,  followed  by  a  i  to  5000  bichlorid  of  mercury 
solution.  The  bladder  is  emptied  and  thoroughly  irrigated  and  from 
4  to  6  ounces  (120  to  180  c.c.)  of  sterile  water  are  allowed  to  remain 
for  purposes  of  distention. 


68o  THE   BLADDER 

Technic. — Having  tested  the  cystoscope  and  the  high  frequency 
current,  the  cystoscope,  well  lubricated  and  with  the  electrode  in 
one  of  the  catheter  chambers  is  introduced  into  the  bladder  (see  page 
663).  The  end  of  the  wire  to  be  introduced  into  the  tumor,  should 
have  been  previously  cut  off  flush  with  the  insulation.  The  tumor 
is  located  and  the  electrode  is  inserted  into  it  as  near  the  base  as 


Fig.  703.— Destruction  of  vesical  growth  by  means  of  the  high  frequency  current 

(After  Oudin.) 

possible  (Fig.  703).  The  current  is  then  turned  on  for  15  to  30  sec- 
onds and  a  rapid  blanching  of  the  tissues  at  the  point  of  contact 
occurs.  The  wire  is  then  allowed  to  cool  and  is  reinserted  into 
another  portion  of  the  tumor  and  the  dessication  continued  until  the 
whole  mass  has  been  treated.  At  subsequent  treatments  portions  of 
the  growth  that  remain  viable  are  similarly  dealt  with.  When  the 
entire  mass  has  sloughed  away  the  base  is  likewise  treated. 

CATHETERIZATION  OF  THE  BLADDER 

Catheterization  of  the  bladder  is  indicated  in  all  cases  of  complete 
retention  of  urine  and  in  some  cases  of  partial  retention,  as,  for 
example,  in  prostatic  hypertrophy  when  the  residual  urine  amounts 
to  more  than  2  ounces  (60  c.c).  Retention  may  be  the  result  of 
obstruction  from  stricture,  spasm  of  the  compressor  urethrse  muscle, 
hj-pertrophy  or  congestion  of  the  prostate,  clots  of  blood,  calculi, 
foreign  bodies  or  tumors  in  the  bladder  or  urethra,  perineal  abscess, 
traumatism,  etc.,  etc.,  and  as  the  result  of  defective  expulsion  power 
of  the  bladder  through  impairment  of  the  nervous  mechanism,  as  in 
hysteria,  certain  diseases  of  the  brain  and  spina]  cord,  shock,  fevers, 


CATHETERIZATION    OF   THE   BLADDER 


68l 


after  the  use  of  certain  drugs,  following  rectal  operations,  etc.,  etc. 
The  probable  cause  of  the  retention  should,  if  possible,  be  ascertained 
before  attempts  to  pass  a  catheter  are  made. 

Retention  may  come  on  suddenly  or  gradually.  In  the  presence 
of  acute  retention  there  is  great  desire,  but  inability,  to  urinate,  ac- 
companied by  a  severe  and  aching  pain  in  the  abdomen  and  perineum. ' 


Fig.  704. — Soft-rubber  catheter. 

Unless  the  condition  is  reheved,  the  symptoms  rapidly  grow  worse 
and  the  patient  lapses  into  a  comatose  state.  When  the  retention  is 
gradual  in  onset,  these  severe  symptoms  are  sometimes  absent  even 
in  cases  of  enormous  distention,  and  it  may  be  only  the  dribbling  of 
the  overflow  from  the  overdis tended  bladder  that  the  patient  com- 
plains of,  the  so-called  "false  incontinence."  Physical  examination 
will,  however,  reveal  an  elastic  fluctuating  tumor  occupying  the 


Fig.  705. — Silver  catheter. 


and   becomes   more 


hypogastrium,    which    is    dull    on    percussion 
prominent  with  the  patient  standing  erect. 

Instruments. — An  assortment  of  the  various  forms  of  catheters 
should  be  on  hand.  For  the  ordinary  cases  of  retention,  uncompli- 
cated by  stricture  or  an  enlarged  prostate,  a  soft-rubber  Nelaton 
(Fig.  704)  or  a  blunt  silver  catheter  with  a  short  curve  (Fig  705)  may 
be  employed. 


682 


THE   BLADDER 


In  the  presence  of  strictures  a  gum  elastic  olivary  catheter  (Fig. 
706)  and  a  set  of  Gouley's  tunneled  catheters  and  filiforms  (Fig.  707) 
will  be  required.  In  place  of  the  latter  a  whip  catheter  (Fig.  708) 
may  be  employed.  This  consists  of  a  flexible  gum  elastic  catheter 
tapering  off  for  several  inches  into  a  filiform. 


Fig.  706. — Gum-elastic  olivary  catheter. 


Fig.  707. — Gouley's  tunneled  catheter  and  filiform. 


Fig.  708. — Whip  catheter. 

The  best  form  of  catheter  to  use  when  the  prostate  is  enlarged  is  a 
Mercier  coude  catheter  (Fig.  709) .  The  slight  angle  at  the  end  of  this 
instrument  permits  it  to  override  an  obstruction.  Guyon's  mandarin 
coude  catheter  (Fig.  710)  and  a  long-curved  silver  prostatic  catheter 
(Fig.  711)  should  also  be  provided.     The  caUber  of  the  instruments 


CATHETERIZATION    OF    THE   BLADDER 


683 


for  this  class  of  cases  should  be  fairly  small,  say  from  15  to  18  French. 

Asepsis. — The  greatest  care  should  be  taken  to  avoid  infection  of 

the  bladder.     Metal  and  rubber  catheters,  as  well  as  the  better  make 


Fig.   709. — Catheters  with  a  coude  and  bicoude  curve. 

gum  elastic  instruments  are  boiled  for  five  minutes.  Instruments 
that  will  not  stand  boiling  are  sterilized  by  formalin  vapor  (page  587) 
or  by  immersion  in  a  i  to  20  carbolic  acid  solution  followed  by  rinsing 


Fig.  710. — Guyon's  mandarin  coude  catheter. 

in  sterile  water.     The  operator's  hands  are  to  be  sterilized  as  carefully 
as  for  any  operation. 

Quantity  of  Urine  Withdrawn. — Except  when  the  distention  is 
slight  and  of  short  duration,  the  bladder  should  not  be  emptied  com- 


FiG.   711. — Silver  prostatic  catheter. 

pletely  at  the  first  catheterization.  As  the  result  of  long-standing 
vesical  distention  there  occurs  a  dilatation  of  the  ureters  and  renal 
pelvis  with  changes  in  the  kidney  structure,  and  a  sudden  evacuation 
of  the  urine  is  apt  to  be  followed  by  suppression  of  urine;  or  hemor- 


684 


THE   BLADDER 


rhage  from  the  vesical  mucous  membrane  or  kidneys  may  result  from 
the  sudden  relief  of  pressure  upon  the  distended  veins.  Therefore, 
not  more  than  8  ounces  (240  c.c.)  of  urine  should  be  withdrawn  at  the 
lirst  catheterization,  gradually  increasing  the  amount  at  subsequent 
catheterizations. 


Fig.  712. — Showing  the  method  of  passing  a  soft-rubber  catheter. 


Fig.  713. — Showing  soft-rubber  catheter  passed  into  the  bladder. 

Frequency. — As  a  rule,  in  complete  retention  the  bladder  requires 
emptying  every  four  to  eight  hours.  When  the  catheter  is  employed 
for  withdrawing  the  residual  urine  of  prostatic  hypertrophy  the 
frequency  will  depend  upon  the  amount  of  residual  urine.  Thus,  if 
Ihis  amounts  to  from  2  to  4  ounces  (60  to  120  c.c),  one  daily  catheter- 


CATHETERIZATION    OF    THE   BLADDER 


685 


ization  before  the  patient  retires  in  the  evening  will  suffice;  if  it 
amounts  to  from  4  to  6  ounces  (120  to  180  c.c),  the  catheter  should 
be  used  twice  a  day,  i.e.,  in  the  evening  and  morning;  larger  quanti- 
ties of  residual  urine  demand  that  the  bladder  be  emptied  three  or 
four  times  a  day. 

Position  of  Patient. — Catheterization  should  always  be  performed 
with  the  patient  recumbent,  as  shock  or  other  unexpected  symptoms 
may  appear  at  any  time  during  the  operation.     The  patient  is  there- 


PiG.  714. — Showing  an  ordinary  catheter  obstructed  by  an  enlarged  middle  lobe  of 

the  prostate  gland. 

fore  placed  in  the  dorsal  position  with  his  shoulders  slightly  raised 
and  thighs  somewhat  flexed  and  rotated  slightly  outward. 

Preparation  of  Patient. — The  glans  penis  and  meatus  should  be 
washed  with  soap  and  water,  followed  by  a  i  to  5000  bichlorid  of 
mercury  solution  and  then  sterile  water.  The  urethra  is  irrigated 
with  a  warm  saturated  solution  of  boric  acid  or  a  i  to  5000  solution 
of  potassium  permanganate. 

Technic. — i.  In  Cases  Uncomplicated  by  Stricture  or  Enlarged 
Prostate. — A  full-sized  soft-rubber  catheter  is  tried  first.  It  is  well 
lubricated  and,  while  the  penis  is  held  upright,  is  slowly  fed  into  the 
urethra  a  little  at  a  time  (Fig.  712).  If  the  catheter  becomes  ob- 
structed, the  penis  should  be  put  upon  the  stretch  to  obliterate  any 
wrinkles  in  the  mucous  membrane,  and  the  instrument  is  again 
advanced  as  before  or  by  rotating  it  while  the  attempt  is  made  to 


686 


THE  BLADDER 


make  it  pass.  In  this  way  a  soft  instrument  can  usually  be  made  to 
enter  the  bladder  when  the  retention  is  simply  due  to  defective  expul- 
sive power.  In  withdrawing  a  catheter  the  instrument  should  be 
compressed  between  1  he  thumb  and  forefinger,  or  the  tip  of  the  finger 
should  be  placed  over  the  opening  at  the  proximal  end  to  prevent 
the  urine  which  remains  in  the  catheter  from  dripping  out  and  wetting 
the  patient's  clothes. 

In  cases  of  spasmodic  stricture,  failing  in  attempts  to  pass  a  soft 
instrument,  a  full-sized  metal  catheter  should  be  resorted  to.  Such 
a  catheter  is  passed  precisely  as  one  would  a  sound  (see  page  587). 


Fig.  715. — Showing  a  coude  catheter  passing  the  obstruction. 

When  the  point  of  the  instrument  has  been  introduced  as  far  as  the 
obstruction,  it  should  be  held  pressing  steadily  against  the  face  of 
the  stricture  for  a  few  minutes  until  the  spasm  passes  off,  when  it 
may  be  easily  slipped  into  the  bladder. 

2.  In  the  Presence  of  Stricture. — In  dealing  with  a  retention  due  to 
stricture  a  small  soft-rubber  catheter  should  be  given  first  trial.  If 
unsuccessful,  attempts  may  be  made  to  pass  an  olivary  pointed 
catheter.  If  this  fails,  a  filiform  should  be  introduced  through  the 
stricture  (see  page  636)  and  a  Gouley  tunneled  catheter  passed  over 
this  as  a  guide,  or,  in  its  stead,  a  whip  catheter  may  be  employed. 
Should  the  stricture  be  of  such  small  caliber  that  it  is  only  possible 
to  insert  a  filiform,  the  latter  should  be  left  in  place  to  act  as  a  capillary 
drain,  taking  care,  however,  to  fasten  it  in  such  a  way  that  it  cannot 
slip  out  (page  691).     In  this  way  the  bladder  will  empty  itself  in  a 


CATHETERIZATION    IN    THE    FEMALE  687 

few  hours  and,  by  the  end  of  twenty-four  hours,  sufficient  dilatation 
wiJl  usually  have  taken  place  to  allow  the  passage  of  a  tunneled 
catheter.  Failing  to  pass  even  a  filiform  the  bladder  should  be 
aspirated  (page  692). 

3.  In  the  Presence  of  Prostatic  Hypertrophy. — A  soft  flexible  cath- 
eter should  be  tried  and  then  a  coude  catheter.  The  latter  will  often 
succeed  where  a  soft  catheter  fails  because  the  bend  of  the  tip  of  this 
instrument  keeps  the  point  in  contact  with  the  upper  wall  of  the  ure- 
thra and  thus  permits  it  to  more  easily  override  a  median  prostatic 
enlargement  (Fig.  715).  Sometimes,  if  an  ordinary  coude  catheter 
will  not  pass,  an  elbowed  catheter  with  a  stylet  can  be  made  to  do  so. 
With  this  instrument  it  is  possible  to  elevate  the  point  more  sharply, 
when  obstructed,  by  withdrawing  the  mandarin  a  little,  so  that  the 
point  of  the  instrument  passes  upward  over  the  obstruction  into  the 
bladder. 

After  repeated  and  unsuccessful  efforts  with  the  above  instrument 
a  metal  prostatic  catheter  should  be  tried  before  resorting  to  aspira- 
tion. Great  gentleness  should  be  employed  in  its  introduction  to 
avoid  making  a  false  passage.  Sometimes  assistance  in  guiding  its 
point  may  be  derived  from  placing  a  finger  in  the  rectum. 

CATHETERIZATION  IN  THE  FEMALE 

Catheterization  of  the  female  bladder  is  a  simple  procedure.  It 
should  always  be  done,  however,  by  direct  sight;  the  old  method  of 
passing  a  catheter  by  touch  carries  with  it  the  great  risk  of  infection. 


Fig.  716. — Glass  female  catheter.      (Ashton.) 

Instruments. — A  glass  female  catheter,  5  inches  (13  cm.)  long  and 
1/5  of  an  inch  (5  mm.)  in  diameter  with  a  gentle  curve  in  opposite 
directions  at  both  ends  (Fig.  716),  is  the  best  instrument  to  employ. 

Asepsis. — The  catheter  is  boiled  for  five  minutes  and  the  opera- 
tor's hands  are  carefully  scrubbed  in  soap  and  water,  followed  by 
immersion  in  an  antiseptic  solution. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  position 
with  the  thighs  flexed  and  the  legs  well  separated. 

Preparations  of  Patient. — The  external  genitals  and  meatus  are 
cleansed  with  soap  and  water  followed  by  a  i  to  50C0  bichlorid  of 
mercury  solution. 


688 


THE   BLADDER 


Technic. — The  operator  separates  the  labia  with  the  thumb  and 
forefinger  of  the  left  hand  so  as  to  expose  the  meatus.  The  catheter, 
held  near  the  proximal  end  in  the  fingers  of  the  right  hand,  is  then 


Fig.  717. — Method  of  passing  a  catheter  in  the  female.      (Ashton.) 


Fig.  718. — Showing  the  method  of  preventing  urine  dripping  from  the  catheter  as 
it  is  withdrawn.      (Ashton.) 

introduced  through  the  urethra  into  the  bladder  (Fig.  717).  When 
the  bladder  has  been  emptied,  the  forefinger  is  first  placed  over  the 
proximal  end  of  the  catheter  to  prevent  the  escape  of  the  urine  it 
contains  (Fig.  718)  and  the  instrument  is  then  withdrawn. 


CONTINUOUS    CATHETERIZATION 


689 


CONTINUOUS  CATHETERIZATION 

A  catheter  may  be  introduced  into  the  bladder  and  left  in  place  in 
cases  where  drainage  of  the  bladder  for  a  brief  period  is  desired.  It 
may  be  employed  in  chronic  cystitis  accompanied  by  the  presence  of 
large  amounts  of  pus,  frequent  urination,  and  tenesmus,  in  vesical 


^. 


Fig.  719. — The  Pezzer  retention  catheter. 

hemorrhage,  and  in  cases  of  obstruction  from  an  enlarged  prostate 
where  the  constant  introduction  of  a  catheter  causes  spasm  or  hemor- 
rhage, or  where  catheterization  is  difhcult.  The  bladder  is  thus  put  at 
rest  and  at  the  same  time  is  kept  constantly  emptied,  the  beneficial 


^^ 


Fig.  720. — The  Malecot  retention  catheter. 

effects  of  which  are  shown  by  a  rapid  decrease  of  the  inflammation 
and  congestion,  decline  of  the  fever,  and  relief  of  the  pain  and  tenes- 
mus. Continuous  catheterization  is  also  indicated  in  wounds  of  the 
urethra  or  after  certain  operations  upon  the  urethra  when  it  is  desir- 
able to  prevent  the  contact  of  infected  urine  with  raw  surfaces. 


Fig.  721. — Stylet  in  place  in  Malecot  catheter,     a,  Mandarin  pushed  forward;  b, 

mandarin  withdrawn. 

At  first,  when  the  catheter  is  inserted,  there  may  be  a  feeling  of 
weight  in  the  perineum,  but  this  soon  passes  off.  In  some  instances  a 
mechanical  urethritis  is  set  up  which  may  persist  until  the  instrument 
is  removed  and,  if  neglected,  urethral  abscess  or  extension  of  the 
infection  backward  into  the  bladder  may  result. 
44 


690  THE  BLADDER 

Instruments. — A  simple  soft-rubber  catheter  of  about  18  French 
with  the  eye  near  the  end  or  the  retention  catheters  of  Pezzer  or 
Malecot  may  be  employed.  The  Pezzer  catheter  (Fig.  719)  has  a 
flange  to  rest  against  the  vesical  neck,  while  the  ]\Ialecot  instrument 
(Fig.  720)  has  wings  on  either  side.  When  introduced  over  a  stylet 
(Fig.  721),  these  projections  are  made  to  disappear,  but  reappear 
when  the  stylet  is  removed. 

Asepsis. — The  catheter  should  be  thoroughly  sterilized  by  boiling 
or  by  formalin  vapor  and,  if  the  latter  method  is  employed,  care  must 
be  taken  to  remove  all  trace  of  the  formalin  by  thoroughly  rinsing  the 
catheter  in  sterile  water.  The  operator's  hands  should  hkewise  be 
perfectly  sterile. 

Duration. — This  will  depend  upon  the  toleration  of  the  urethras 
In  some  cases,  continuous  drainage  may  be  kept  up  for  over  two  week. 


Fig.  722. — Showing  the  method  of  securing  a  catheter  in  the  bladder.     (After 
Sinclair,  Polyclinic  Journal,  July,  1908.) 

without  the  catheter  causing  much  irritation;  in  others,  the  presence 
of  an  instrument  in  the  bladder  produces  so  much  irritation  and  ves- 
ical spasm  thai  it  cannot  be  used  at  all. 

Preparation  of  Patient. — The  glans  penis  and  meatus  are  washed 
with  soap  and  water  followed  by  a  i  to  5000  solution  of  bichlorid  of 
mercury,  and  the  urethra  is  thoroughly  irrigated  with  a  mild  anti- 
septic solution. 

Technic. — i.  By  the  Ordinary  Catheter. — If  a  simple  rubber 
catheter  is  employed,  it  is  well  lubricated  and  is  then  introduced  in 
the  usual  way  until  its  eye  lies  just  within  the  bladder.  It  is  quite 
important  that  the  point  of  the  catheter  be  not  introduced  too  far, 
for,  if  so,  it  will  not  only  fail  to  drain  the  bladder  properly,  but  will 
irritate  the  vesical  floor.  To  insure  that  the  instrument  is  properly 
placed,  it  should  first  be  introduced  into  the  bladder  imtil  the  urine 
flows  freely  and  then  slowly  withclra^vn  until  the  flow  just  stops, 
when  it  is  pushed  into  the  bladder  again,  this  time  for  a  distance  of 
1/4  inch  (6  mm.).     It  is  then  secured  in  place  as  follows: 


CONTINUOUS    CATHETERIZATION 


691 


The  portion  of  the  catheter  protruding  from  the  meatus  is  thor- 
oughly dried  and  all  grease  is  removed.  Then  four  pieces  of  adhesive 
plaster,  each  about  4  inches  (12  cm.)  long  and  1/4  inch  (6  mm.)  wide, 
are  secured  to  the  catheter  at  the  point  it  emerges  from  the  meatus  in 
such  a  way  that  one  strip  lies  upon  the  dorsum,  one  on  the  ventral 
surface,  and  one  on  either  side  of  the  penis.  Each  strip  is  carried 
back  over  the  foreskin  and  is  made  to  adhere  to  the  body  of  the  penis. 
An  additional  strip  of  adhesive  i  inch  (2.5  cm.)  wide  is  placed  hori- 
zontally about  the  penis  back  of  the  corona,  covering  the  four  small 
strips  (Fig.  722).  Care  should  be  taken,  however,  not  to  have  this 
strip  entirely  encircle  the  penis.  The  penis  is  then  wrapped  in  sterile 
gauze  and  is  supported  over  one  groin  by  a  T-bandage.     If  upon 


Fig.  723. — Malecot  retention  catheter  in  place  in  the  bladder. 

inspection  it  is  found  that  the  urine  escapes  freely,  the  free  end  of  the 
catheter  is  finally  connected  with  a  drainage-tube  which  conducts 
the  urine  to  a  receptacle  at  the  side  of  the  bed.  The  receptacle 
should  be  half-full  of  some  antiseptic  solution. 

If  the  retained  catheter  is  employed  in  a  case  of  long-standing 
retention  where  it  is  dangerous  to  empty  the  bladder  at  once,  an 
intermittent  form  of  drainage  may  be  employed  by  discarding  the 
drainage-tube  and  simply  inserting  a  plug  in  the  end  of  the  catheter, 
which  is  removed  at  definite  intervals  and  an  increasing  quantity  of 
the  urine  drawn  off  each  time  until  it  is  considered  safe  to  empty  the 
bladder  completely,  when  the  above  method  is  used. 

2.  By  the  Self -retaining  Catheter. — In  inserting  a  special  self-retain- 
ing catheter,  a  stylet  curved  to  the  shape  of  a  sound  is  introduced 
within  the  instrument  so  as  to  obliterate  the  projecting  collar  or 
wings  (see  Fig.  721).     When  the  catheter  is  in  place,  the  stylet  is 


692  THE   BLADDER 

withdrawn,  thus  allowing  the  bladder  end  of  the  catheter  to  expand 
again  so  that  the  catheter  is  retained  in  place  unless  some  force  is 
used  in  withdrawing  it  (Fig.  723).  In  spite  of  this,  however,  it  is 
safer  to  fix  the  catheter  in  place  by  the  method  above  described, 
after  first  withdrawing  it  until  the  resistance  shows  that  the  terminal 
enlargement  is  at  the  vesical  neck. 

After-care. — The  catheter  rapidly  becomes  encrusted  with  lime 
salts,  blood,  or  pus  and  should,  therefore,  be  changed  every  two  or 
three  days  to  permit  of  its  being  cleansed.  At  this  time  the  urethra 
and  bladder  should  be  thoroughly  irrigated  with  a  mild  antiseptic 
solution  and  the  catheter  thoroughly  sterilized  before  it  is  reinserted. 
In  the  presence  of  pus  or  blood  the  bladder  may  be  irrigated  through 
the  catheter  as  frequently  as  seems  indicated. 

If  urethritis  develops,  the  urethra  should  be  irrigated  once  or 
twice  daily  with  a  saturated  solution  of  boric  acid.  This  may  be 
accomplished  by  withdrawing  the  catheter  until  its  extremity  lies 
in  front  of  the  bulbous  urethra  and  then  flushing  out  the  urethra 
from  behind  through  the  instrument  by  means  of  an  irrigating  appa- 
ratus. The  catheter  is  then  pushed  back  to  its  original  position. 
Constant  watch  should  be  kept  lest  ulceration  of  the  urethral  wall 
develop  at  the  penoscrotal  junction  from  pressure  of  the  catheter. 
To  avoid  this,  the  penis  should  be  supported  in  such  a  position  that 
the  sharp  angle  formed  at  the  penoscrotal  junction  when  the  organ 
hangs  vertically  is  obliterated. 

ASPIRATION  OF  THE  BLADDER 

Suprapubic  aspiration  of  the  bladder  is  indicated  as  a  temporary 
expedient  when  there  is  complete  retention  of  urine  and  catheteriza- 
tion is  impossible  from  the  presence  of  a  tight  stricture,  prostatic 
enlargement,  or  from  any  other  cause.  The  operation  is  easily 
performed  and,  if  properly  done,  is  a  safe  procedure.  At  times  after 
a  single  aspiration  the  congestion  is  so  much  lessened  that  within  a 
few  hours  it  becomes  possible  to  pass  a  catheter,  or  the  patient  voids 
spontaneously,  but,  if  necessary,  the  bladder  may  be  emptied  several 
times  a  day  for  several  days  by  this  method  without  danger. 

Where  a  permanent  drainage  for  some  time  is  desired,  suprapubic 
puncture  by  means  of  a  trocar  and  cannula  may  be  performed. 
Puncture  through  the  perineum  or  rectum,  on  the  other  hand,  should 
be  avoided  as  unsafe. 

Instruments. — For  temporary  relief  an  aspirating  needle  and 
syringe  should  be  employed.     The  needle  should  be  fairly  fine  and 


ASPIEATON    OF    THE   BLADDER 


693 


about  3  inches  (7.5  cm.)  long.  The  Potain  aspirator  (Fig.  724)  is 
the  best  to  use.  This  instrument  has  already  been  described 
(page  286). 

When  a  trocar  and  cannula  are  used,  a  curved  instrument  with 
the  convexity  of  the  curve  upmost  should  be  obtained.  A  scalpel  to 
nick  the  skin  is  also  required. 

Asepsis. — The  instruments  are  boiled  for  five  m.inutes  in  a  i  per 
cent,  sodium  carbonate  solution  and  the  operator's  hands  are  sterilized 
in  the  usual  way  as  for  any  operation. 

Site  of  Puncture. — The  puncture  is  made  in  the  median  line  about 
1/2  inch  (i  cm.)  above  the  pubes.     The  extraperitoneal  space  above 


Fig.  724. — Potain  aspirator. 


the  pubic  bone  is  increased  when  the  bladder  is  distended  and  a  needle 
or  trocar  may  be  inserted  here  without  danger  of  entering  the  perito- 
neum. When  a  number  of  punctures  are  made,  the  site  may  be 
changed  a  little  each  time. 

Position  of  Patient. — The  operation  may  be  performed  with  the 
patient  recumbent  or  sitting  partly  up. 

Preparations  of  Patient.^-^The  pubes  should  be  shaved  and  then 
painted  with  tincture  of  iodin. 

Anesthesia. — Sufficient  anesthesia  is  obtained  by  freezing  the 
surface  tissues  with  ethyl  chlorid  or  salt  and  ice  to  render  the  opera- 
tion painless. 

Technic. — i.  By  the  Aspirator. — The  suprapubic  region  is  first 
carefully  percussed  to  make  sure  that  there  are  no  coils  of  intestine 


694  THE   BLADDER 

lying  in  front  of  the  bladder.  The  aspirator  is  assembled,  tested,  and 
the  air  in  the  bottle  exhausted.  A  small  nick  is  then  made  in  the 
skin  at  the  spot  chosen  for  the  puncture  and  the  needle,  held  in  the 
right  hand  with  the  index-finger  placed  on  its  shaft  as  a  guide,  is 
introduced  through  the  tissues,  directed  downward  and  backward, 
until  a  lessened  resistance  signifies  that  the  bladder  has  been  entered 
This  will  usually  be  when  the  needle  has  entered  from  i  1/2  to  2  1/2 
inches  (4  to  6  cm.),  depending  upon  the  thickness  of  the  abdominal 
wall.  The  aspirator  is  then  attached  and  the  vacuum  is  extended  to 
the  needle-point  by  opening  the  inflow  cock.  If  no  urine  is  with- 
drawTi,  the  needle  is  introduced  still  further  until  fluid  is  reached. 
The  contents  of  the  bladder  are  then  partly  or  completely  emptied, 
depending  upon  the  duration  of  the  retention  and  the  amount  of  the 
distention  (see  page  683). 

In  removing  the  needle,  care  should  be  taken  to  keep  up  the  suc- 
tion until  the  needle  is  completely  withdrawn,  otherwise  some  urine 
may  escape  from  the  tip  of  the  needle  as  it  traverses  the  prevesical 
space  and  cause  an  infection.  The  site  of  the  puncture  is  finally 
covered  with  a  piece  of  sterile  gauze  held  in  place  by  adhesive  plaster. 

2.  By  the  Trocar  and  Cannula. — A  small  nick  is  made  in  the  skin 
as  before  at  the  chosen  site  and  through  this  the  trocar  and  cannula 
with  the  convexity  up  is  inserted  into  the  bladder,  care  being  taken  to 
guard  against  the  instrument  entering  too  deeply  by  placing  the  index- 
finger  on  the  shaft  of  the  instrument  as  a  guide.  The  trocar  is  then 
removed  and  the  cannula  is  secured  in  place  for  permanent  drainage 
by  means  of  tapes.  A  rubber  drainage-tube  leading  to  a  receptacle 
half  filled  with  an  antiseptic  solution  is  fastened  to  the  cannula. 

The  bladder  may  be  irrigated  through  the  cannula  once  or  twice 
daily  if  it  contains  much  pus.  The  cannula  should  be  removed  and 
sterilized  every  few  days.  To  do  this  a  small  catheter  is  passed 
through  the  lumen  of  the  cannula  into  the  bladder  where  it  is  main- 
tained while  the  catheter  is  being  cleansed.  The  cannula  is  then  easily 
reintroduced  over  the  catheter  as  a  guide. 

The  permanent  cannula  should  be  removed  as  soon  as  it  is  possible 
to  pass  a  catheter  through  the  urethra  without  difficulty.  The  sinus 
remaining  is  allowed  to  close  by  granulation. 


CHAPTER  XXI 
THE  KIDNEYS  AND  URETERS. 

Anatomic  Considerations 

The  Kidneys. — The  kidneys  are  two  bean-shaped  organs,  each 
measuring  on  an  average  from  4  to  4  3/4  inches  (10  to  12  cm.)  in 
length  and  2  1/2  inches  (6  cm.)  in  breadth.  They  he  deeply  situated 
in  the  abdominal  cavity  on  each  side  of  the  vertebral  column,  behind 
the  peritoneum  embedded  in  a  loose  layer  of  areolar  tissue,  the  peri- 
renal fat,  resting  upon  the  diaphragm,  the  quadratus  lumborum, 


Fig.  725. — The  position  of  the  kidneys  and  course  of  the  ureters  from  behind. 

and  psoas  muscles.  Surrounding  the  perirenal  fat  is  a  layer  of  fascia, 
complete  except  along  the  inner  border  of  the  kidney  and  at  its  lower 
pole,  which  is  firmly  attached  to  the  spine  and  diaphragm,  and  serves 
to  anchor  the  kidney  in  place. 

The  position  of  the  kidneys  from  behind  corresponds  to  the  space 
between  the  upper  border  of  the  twelfth  dorsal  vertebra  and  the  first 
and  second,  or  third,  lumbar  vertebrae.  The  right  kidney  generally 
lies  about  1/3  to  1/2  inch  (0.7    to  i  cm.)  lower  than  the  left  on 

69s 


696 


THE  KIDNEYS  AND  URETERS 


account  of  the  position  of  the  hver  above  it.  the  upper  extremity  of 
the  right  kidney  usually  reaching  to  the  level  of  the  lower  border  of 
the  eleventh  rib  and  that  of  the  left  to  the  upper  border  of  the  eleventh 
rib.  The  inferior  poles  of  the  kidneys  reach  to  within  i  1/2  inches 
(4  cm.)  on  the  right  and  to  within  2  inches  (5  cm.)  on  the  left  of  the 
crest  of  the  ilium.  During  deep  inspiration  or  when  the  patient 
stands  erect  the  kidney  will  descend  to  a  somewhat  lower  level.  The 
long  axis  of  the  kidney  is  directed  obliquely  downward  and  outward, 


Fig.  726. — The  kidneys  and  ureters  from  the  front. 

so  that  the  superior  poles  lie  from  1/2  to  i  inch  (i  to  2.5  cm.)  nearer 
the  median  line  than  the  lower  poles. 

Anteriorly,  the  position  of  the  kidney  may  be  mapped  out  b}^  pass- 
ing a  horizontal  line  through  the  umbihcus  and  a  vertical  line  from 
the  middle  of  Poupart's  ligament  to  the  costal  border  perpendicular 
to  the  horizontal  line — the  former  passes  just  below  the  lower  poles 
of  the  kidneys,  while  the  latter  cuts  the  long  axis  of  the  kidney  at  the 
junction  of  its  middle  and  outer  thirds.  If  the  kidney  lies  to  the  outer 
side  of  the  vertical  line  or  below  the  horizontal  umbilical  line,  it  is 
indicative  of  enlargement  or  a  displacement. 

Relations  of  Kidneys. — Behind,  the  kidneys  are  in  relation  with 
the  diaphragm,  quadratus  lumborum,  psoas  muscles,  and  with  the 
last    dorsal,    iliohypogastric,    and    ilioinguinal    nerves.     The    close 


ANATOMIC    CONSIDERATIONS  697 

relations  of  these  nerves  account  for  the  referred  pains  sometimes 
encountered  in  diseases  of  the  kidneys. 

In  front  of  the  right  kidney  are  the  under  surface  of  the  right  lobe 
of  the  liver,  the  second  portion  of  the  duodenum,  the  ascending  colon, 
and  the  hepatic  flexure.  The  left  kidney  is  in  relation  in  front  with 
the  spleen,  the  fundus  of  the  stomach,  the  tail  of  the  pancreas,  the 
splenic  vessels,  and  the  descending  colon. 

Ureters. — The  ureters  are  two  in  number,  one  for  each  kidney. 
They  are  about  12  inches  (30  cm.)  in  length  and  have  a  caliber  equal 
to  that  of  a  goose  quill.  The  ureter  begins  at  the  neck  of  the  renal 
pelvis  opposite  the  lower  pole  of  the  kidney  and  passes  down  on  the 
psoas  muscle  behind  the  peritoneum  to  the  brim  of  the  pelvis.  A  line 
drawn  on  the  abdominal  wall  vertically  upward  from  the  junction  of 
the  middle  and  inner  thirds  of  Poupart's  ligament  roughly  represents 
the  course  of  the  ureter  from  the  kidney  to  the  pelvic  brim. 

The  ureter  in  the  male,  after  crossing  the  pelvic  brim  and  the 
common  ihac  vessels,  passes  downward  and  backward  in  front  of  the 
sacroiliac  joint  and  enters  the  parietal  attachment  of  the  posterior 
false  ligament  of  the  bladder.  It  then  passes  forward  and  inward  to 
the  base  of  the  bladder  which  it  enters  just  above  the  seminal  vesicle, 
first  passing  under  the  vas  deferens. 

The  ureter  in  the  female,  after  crossing  the  pelvic  brim  and  iliac 
vessels,  passes  downward  and  backward  along  the  lateral  wall  of  the 
pelvis  as  in  the  male.  It  then  enters  the  base  of  the  broad  ligament 
and  passes  down  parallel  with  the  cervix  and  upper  portion  of  the 
vagina,  at  a  distance  of  about  1/2  inch  (i  cm.)  external  to  the  cervix 
and  posteriorly  to  the  uterine  artery.  After  crossing  the  upper  third 
of  the  vagina  the  ureter  enters  the  bladder  opposite  the  middle  of  the 
vagina.  The  pelvic  portion  of  the  ureter  in  the  female  is  thus  readily 
palpated  through  the  vagina  or  rectum. 

The  ureters  enter  the  bladder  i  1/2  to  2  inches  (4  to  5  cm.)  apart 
and,  after  passing  obliquely  forward  and  inward  for  a  distance  of  3/4 
of  an  inch  (2  cm.)  through  the  bladder  wall,  they  appear  on  the 
mucous  membrane  about  i  1/4  inches  (3  cm.)  apart  and  the  same  dis- 
tance posterior  to  the  internal  urethral  orifice.  Through  this  oblique 
insertion  of  the  ureters  into  the  bladder  regurgitation  of  urine  when 
the  bladder  is  distended  is  effectually  guarded  against. 

The  ureters  are  composed  of  three  coats,  an  outer  fibrous,  a  middle 
or  muscular,  and  an  internal  or  mucous.  Normally  the  walls  are 
collapsed  and  lie  in  contact.  The  lumen  of  the  ureter  presents  three 
constrictions  and  two  intermediate  dilated  portions.      The  constric- 


698  THE   KIDNEYS    AND    URETERS 

tions  are:  First,  about  2  1/2  inches  (6  cm.)  from  the  hilum  of  the 
kidney;  second,  at  the  point  where  the  ureter  crosses  the  pelvic 
brim;  and,  third,  at  its  entrance  into  the  bladder. 


Diagnostic  Methods 

In  suspected  disease  of  the  kidney  or  ureter  a  careful  history  of  the 
past  ailments  and  present  symptoms  should  first  be  obtained.  Fre- 
quently pain  will  be  the  only  symptom  complained  of.  In  such  case 
its  exact  location  should  be  determined;  that  is,  whether  limited  to 
the  loin  or  radiating  along  the  course  of  the  ureter,  and  whether 
unilateral  or  bilateral.  Severe  attacks  of  pain  radiating  from  the  loin 
down  toward  the  bladder,  testicle,  and  thigh  are  strongly  suspicious 
of  calculus.  The  character  of  the  pain  should  also  be  ascertained; 
whether  it  is  dull  or  aching,  or  paroxysmal  and  lancinating,  and 
whether  continuous  or  periodic.  Periodic  attacks  of  sharp  pain 
accompanied  by  a  considerable  diminution  in  the  amount  of  urine 
secreted,  followed  by  relief  of  the  pain  and  an  abundant  flow  of  urine 
are  characteristic  symptoms  of  hydronephrosis  due  to  a  movable 
kidney.  The  patient  should  also  be  questioned  as  to  the  character 
of  his  urine,  i.e.,  whether  bloody,  etc.,  supplemented  by  inquiry  as  to 
special  points  along  the  lines  mentioned  in  the  sections  upon  the 
urethra  and  bladder.  This  is  followed  by  a  thorough  physical 
examination. 

Having  obtained  all  the  information  possible  by  these  means,  the 
actual  examination  of  the  organ  under  consideration  may  be  taken  up. 

The  methods  available  for  examination  of  the  kidneys  and  ureters 
include  inspection,  palpation,  percussion,  urinalysis,  cystoscopic 
examination,  ureteral  catheterization,  pyelometry,  segregation  of 
urine,  determination  of  the  functional  capacity  of  the  kidneys, 
skiagraphy,  and  exploratory  incision. 

INSPECTION 

On  account  of  the  deep  situation  of  the  kidney  in  the  abdomen, 
inspection  gives  no  information  if  the  kidney  is  normal.  When,  how- 
ever, the  kidney  is  greatly  enlarged  it  may  produce  a  visible  swelling 
in  the  loin  or  protrude  anteriorly  and  cause  a  bulging  of  the  lower 
ribs  upon  the  side  affected. 

Inspection  should  be  performed  from  in  front  -with  the  patient 
lying  flat  on  the  back,  and  also  from  behind  and  laterafly  with  the 


PALPATION    OF    THE    KIDNEYS 


699 


patient  standing  and  bending  forward,  so  as  to  make  any  bulging 
more  prominent  through  relaxation  of  the  abdominal  muscles. 

PALPATION  OF  THE  KIDNEYS 

Palpation  is  by  far  the  most  valuable  of  the  methods  of  physical 
diagnosis  for  determining  the  presence  of  enlargement  or  displace- 
ments of  the  kidney.  While  the  normal  kidney  can  seldom  be  felt, 
unless  the  individual  is  very  thin  and  the  abdominal  wall  is  lax,  and 
then  it  is  only  possible  to  palpate  the  lower  pole  of  the  kidney,  an 
increase  in  the  size  of  the  organ  or  undue  mobility  is  readily  recog- 
nized. By  palpation  it  is  also  possible  to  determine  the  sensitiveness 
of  the  kidney  and  in  the  presence  of  a  tumor,  its  characteristics — 
namely,  its  size,  sl^ape,  and  whether  soft,  hard,  or  fluctuating. 

Palpation  is  sometimes  performed  with  one  hand,  so  placed  that 
the  fingers  press  in  the  loin  while  the  thumb  lies  on  the  abdomen 
beneath  the  costal  arch,  but  a  more  satisfactory  method  is  the 
bimanual. 


Fig.  727. — Palpation  of  the  kidney  with  the  patient  in  the  dorsal  position. 


Position  of  Patient. — The  patient  should  lie  flat  on  the  back  with 
the  head  and  shoulders  elevated  upon  a  small  pillow  and  the  lower 
extremities  flexed  so  as  to  thoroughly  relax  the  abdominal  walls. 
Sometimes  in  cases  of  movable  kidney  additional  information  may  be 
elicited  by  palpating  with  the  patient  standing,  his  body  bcDt  forward 
from  the  hips,  and  with  his  hands  resting  on  the  arm  of  a  chair  for 
support;  or  else  the  patient  may  assume  the  lateral  position,  lying  on 
the  sound  side,  and  with  the  thighs  slightly  flexed  (see  Fig.  728). 


?oo 


THE  KIDNEYS  AXD  URETERS 


Preparations  of  Patient. — Care  should  be  taken  to  have  the  colon 
empty  at  the  time  of  the  examination;  if  necessary  a  cathartic  should 
be  administered  the  night  before  for  this  purpose.  All  clothing  that 
is  likely  to  interfere  with  the  examination  should  be  removed. 

Anesthesia. — If  palpation  is  difficult  through  rigidity  of  the  ab- 
dominal muscles  or  from  increased  sensitiveness,  a  general  anesthetic 
may  be  required  in  order  to  make  a  satisfactory  examination. 

Technic. — The  examiner  should  stand  upon  the  side  he  wishes  to 
examine.  When  palpating  the  right  kidney  the  fingers  of  the  left 
hand  are  placed  under  the  loin  just  below  the  last  rib  and  the  right 
hand  is  placed  flat  on  the  abdomen  below  the  costal  arch  (Fig.  727); 


Fig.   728. — Palpation  of  the  kidney  with  the  patient  on  the  side. 


to  palpate  the  left  kidney  the  position  of  the  hands  is  reversed.  The 
patient  is  instructed  to  breathe  deeply  but  quietly,  and  any  manipula- 
tions should  be  gentle  in  character  to  avoid  inciting  muscular  con- 
traction. The  kidney  descends  during  inspiration  and,  if  at  this  time 
forward  pressure  is  made  with  the  hand  under  the  loin  and  the  hand 
upon  the  abdomen  is  pressed  backward  under  the  ribs,  the  kidney,  if 
enlarged,  will  be  felt.  If  the  kidney  is  displaced,  it  may  be  caught 
between  the  two  hands  as  it  descends  during  deep  respiration  and 
may  be  prevented  from  returning  to  its  former  position.  In  the 
presence  of  a  tumor,  the  size,  shape,  and  consistence  of  the  growth 
should  be  determined  and  its  sensitiveness  ascertained.  Palpation 
of  the  normal  kidney  causes  a  peculiar  sensation  which  has  been 
likened  to  pressure  on  the  testicle;  actual  pain  will  be  elicited,  how- 
ever, in  the  presence  of  some  tumors,  kidney  calculus,  or  pus 
formation. 

Tumors  of  the  colon,  gall-bladder,  pylorus,  spleen,  or  a  peduncu- 


PALPATION  OF  THE  URETERS  701 

lated  ovarian  or  uterine  growth  may  be  mistaken  for  a  renal  tumor 
or  a  movable  kidney.  The  symptoms  complained  of  and  the  relation 
of  the  colon  of  the  tumor,  however,  will  usually  settle  the  diagnosis. 
The  colon  lies  in  front  or  to  the  inner  side  of  the  kidney  and,  if  neces- 
sary, it  should  be  inflated  to  more  accurately  map  it  out. 

At  times  the  so-called  "ballottement  of  the  kidney"  may  be 
obtained  if  the  kidney  is  freely  movable.  To  elicit  this  sign  sudden 
sharp  pressure  is  applied  to  the  loin  by  the  posterior  hand,  when,  if 
movable  or  enlarged,  the  kidney  will  be  driven  forward  with  a  slight 
impact  against  the  hand  on  the  abdomen  in  front. 

PALPATION  OF  THE  URETERS 

The  ureters  may  be  palpated  through  the  abdominal  wall,  through 
the  vagina,  or  through  the  rectum.  Abdominal  palpation  is  only  of 
value  if  the  patient  is  thin  and  the  abdominal  walls  lax,  and  then  it  is 
only  possible  to  palpate  the  ureter  if  thickened  or  if  it  contains  a 
calculus.  In  some  cases,  however,  if  inflamed  and  painful,  the  ureter 
may  be  traced  from  the  kidney  pelvis  to  the  pelvic  brim  from  the 
pain  elicited  on  palpation.  Through  the  vagina  it  is  possible  to 
palpate  the  ureter  from  the  base  of  the  broad  ligament  to  its  entrance 
into  the  bladder.  Calculi,  thickening,  or  inflammation  of  this  por- 
tion of  the  ureter  is  thus  readily  recognized.  In  the  male  by  rectal 
examination  the  ureter  may  be  palpated  in  its  course  from  the  pelvis 
to  the  bladder. 

Positions  of  Patient. — For  abdominal  palpation  the  patient  should 
lie  flat  on  the  back  with  the  head  and  shoulders  slightly  elevated  and 
the  thighs  flexed. 

Vaginal  or  rectal  palpation  is  performed  in  the  dorsal  position 
with  the  thighs  flexed. 

Preparations  of  Patient. — The  bladder  and  bowels  should  be 
empty  at  the  time  of  examination. 

Technic. — i.  Abdominal  Palpation. —  The  examiner  stands  on  the 
side  to  be  palpated  and  first  locates  the  promontory  of  the  sacrum  by 
deep  palpation  with  the  examining  hand.  The  ureter  crosses  the 
pelvic  brim  at  a  point  about  i  1/4  inches  (3  cm.)  to  the  side  of  the 
promontory  and  a  little  below  it.  A  thickened  ureter  may  be 
palpated  at  this  point  if  the  patient  has  thin,  relaxed  abdominal  mus- 
cles. Beginning  at  this  point,  the  ureter  maybe  traced  upward  along 
its  course  by  making  deep  pressure  along  the  outer  border  of  the  rectus 
muscle  (Fig.  729).     If  the  ureter  is  inflamed,  palpation  will  elicit 


702 


THE    KIDNEYS    AND    URETERS 


pain.     On  the  right  side  such  pain  must  be  differentiated  from  that 
of  cholecystitis  or  appendicitis. 

2.  Vaginal  Palpation. — The  right  hand  is  employed  to  palpate 
the  right  ureter  and  the  left  hand  for  palpation  of  the  left  ureter. 


Fig.  729. — -Abdominal  palpation  of  the  ureter. 


Fig.  730. — Vaginal  palpation  of  the  ureter.      (Ashton.) 


The  index-finger  is  inserted  in  the  vagina  and  is  carried  to  the  vaginal 
fornix  corresponding  to  the  ureter  to  be  palpated.  From  this  point 
it  is  pushed  upward  and  outward  toward  the  pelvic  wall,  and  a  careful 


PERCUSSION 


703 


search  is  made  for  the  ureter  which  will  be  recognized  as  a  flat  cord 
passing  forward  and  inward  from  the  pelvic  wall  around  the  cervix  to 
the  bladder  (Fig.  730).  Sometimes,  by  means  of  a  bimanual  exam- 
ination, with  one  hand  placed  on  the  abdominal  wall  and  exerting 
downward  pressure  the  ureter  may  be  more  satisfactorily  examined. 
3.  Rectal  Palpation. — The  right  hand  palpates  the  right  ureter 
and  vice  versa.  The  index-finger  well  lubricated  is  inserted  into  the 
rectum  and  is  carried  upward  a  little  higher  than  the  level  of  the  base 
of  the  seminal  vesicle.  The  finger  is  then  turned  toward  the  lateral 
wall  of  the  pelvis  and  the  ureter  is  sought  by  moving  the  finger 
backward  and  forward.  It  will  be  recognized  as  a  flat  cord-hke 
structure  passing  at  first  downward  along  the  side  of  the  pelvis  and 


Fig.  731. — Palpation  of  the  ureter  per  rectum. 


then  forward.  It  may  be  traced  as  far  as  the  bladder  and  will  be 
recognized  passing  forward  and  inward  from  the  pelvic  wall  to  the 
base  of  the  bladder,  where  it  will  be  felt  a  little  above  the  seminal 
vesicle. 

PERCUSSION 

Percussion  of  the  kidney  is  of  slight  value  unless  the  organ  is 
greatly  enlarged.  At  best  it  is  diflicult  on  account  of  the  thick  layer 
of  muscles  in  the  dorsal  and  lumbar  regions  and  the  depth  of  the 
kidney  from  the  anterior  abdominal  wall.  In  fat  individuals  the 
difiiculties  are  increased  in  proportion.  Percussion  is  important, 
however,  for  the  purpose  of  showing  the  position  of  the  colon  in 


704 


THE  KIDNEYS  AND  URETERS 


relation  to  a  tumor  occupying  the  region  of  the  kidney  and  in 
differentiating  growths  of  the  kidney  from  the  spleen  and  liver. 

Position  of  Patient. — To  percuss  from  behind  the  patient  should 
lie  face  downward  with  a  firm  cushion  or  several  pillows  under  the 
abdomen  to  make  the  lumbar  region  more  prominent  (Fig.  732). 

For  anterior  percussion  the  patient  lies  in  the  dorsal  posture  with 
the  legs  extended. 

Preparations  of  Patient. — The  colon  must  be  emptied  so  as  not  to 
obscure  the  results. 

Technic. — It  is  necessary  to  employ  very  strong  percussion  to  out- 
line the  organ,  but  in  fat  individuals  even  this  may  yield  unsatis- 
factory results.  In  a  normal  case  the  kidney  dulness  will  be  found 
to  extend  about  2  inches  (5  cm.)  below  the  last  rib.  merging  above 


17  •••; 

Fig.  732. — Position  of  the  patient  for  percussion  of  the  kidneys  from  behind. 


into  that  of  the  liver  or  spleen.  In  a  large  renal  growth  percussion 
will  give  dulness  extending  outward  and  downward  beyond  the  nor- 
mal limits,  with  colon  resonance  in  front  or  internal  to  the  tumor. 

Tumors  of  the  spleen  or  liver  may  give  much  the  same  area  of 
dulness,  but  the  colon  resonance  will  be  behind.  Inflation  of  the 
colon  (page  521)  may  be  necessary  before  its  position  can  be  accur- 
ately determined. 

URINALYSIS 

The  examination  of  the  urine  is  of  the  greatest  importance.  It 
should  comprise  a  complete  physical,  chemical,  microscopical,  and 
bacteriological  analysis.  Abnormality  may  be  due  to  general 
diseases,  renal  diseases,  or  to  lesions  in  1  he  lower  genitourinary  tract, 
so  that  it  is  not  sufficient  to  simply  recognize  a  departure  from  the 
normal,  but  the  seat  of  the  trouble,  i.e.,  whether  in  the  bladder,  ureter, 
or  kidney,  must  be  determined  and,  if  the  ureters  or  kidneys  are 
affected,  which  side  is  involved  as  well.     For  this  purpose  the  cysto- 


CATHETERI2IXG    THE    URETERS  705 

scope  and  ureteral  catheter  are  of  the  greatest  aid.  Other  methods 
for  determining  the  source  of  abnormal  urinary  constituents  have  al- 
ready been  described  (see  page  646). 

CYSTOSCOPY     (See  page  659) 
CATHETERIZING  THE  URETERS 

The  use  of  the  ureteral  catheter  is  of  the  greatest  diagnostic  aid  in 
diseases  of  the  kidney  or  ureter,  as  it  is  possible  by  this  means  to 
collect  urine  separately  from  each  kidney  for  analysis  uncontami- 
nated  by  contact  with  the  bladder  or  urethra,  and  to  explore  the 
entire  length  of  the  ureter  from  the  bladder  to  the  kidney  pelvis. 
This  method  of  examination  is  thus  of  value  in  determining  whether 
both  kidneys  are  present,  in  estimating  the  functional  capacity  of 
either  kidney,  and  in  the  presence  of  blood  or  pus  in  the  urine  in 
determining  whether  its  source  is  the  kidney  or  the  ureter  and  from 
which  side  it  comes.  It  is  also  of  the  greatest  aid  in  recognizing  stric- 
ture or  calculus  of  the  ureter,  hydroureter,  hydronephrosis,  etc. 

Ureteral  catheterization  has  certain  drawbacks  that  should  be 
mentioned.  Under  the  most  favorable  conditions  it  requires  con- 
siderable skill  to  catheterize  the  ureters,  and  in  some  cases,  compli- 
cated by  the  presence  of  tight  urethral  strictures,  enlargement  of  the 
prostate,  tumors,  or  thickening  of  the  bladder  mucous  membrane  it 
may  be  impossible.  Then  there  is  always  present  the  danger  of 
carr)dng  infection  from  the  bladder  into  a  healthy  ureter  or  kidney. 
With  proper  aseptic  precautions  in  performing  the  operation,  how- 
ever, this  danger  may  be  disregarded. 


Fig.  733. — Bransford  Lewis  cystoscope. 

Instruments. — Catheterizing  cystoscopes,  like  the  exploring 
cystoscopes,  are  of  two  t}^es,  the  direct  view  and  the  indirect  \aew. 

The  direct  view  cystoscope,  of  which  the  Brenner,  BroT\Ti. 
Bransford  Lewis,  Eisner,  etc.,  instruments  are  t\-pes.  are  arranged 
with  the  light  either  on  the  convex  side  of  the  beak,  or  with  a  wdndow 
both  on  the  convexity  and  concavity  so  that  the  hght  is  shed  in  both 

45 


706  •  THE    KIDNEYS    AND    URETERS 

directions,  and  are  provided  with  a  straight  observation  telescope 
having  a  window  at  the  distal  end.  The  catheter  chambers  are  placed 
on  the  under  surface  of  the  telescope  so  that  the  catheters  protrude  at 
the  lower  part  of  the  field  of  vision  in  a  straight  Hne.  An  obturator 
takes  the  place  of  the  telescope  when  the  instrument  is  being  inserted 
into  the  bladder. 

The  indirect  catheterizing  cystoscope,  such  as  the  Nitze,  Casper, 
Albarran,  Bierhoff,  Buerger,  etc.,  have  the  Hght  upon  the  concave  side 
of  the  beak,  while  the  image  is  reflected  at  right  angles,  by  means  of  a 
prism,  to  the  eye-piece  at  the  proximal  end.  The  catheter  chambers 
are  enclosed  within  the  sheath  of  the  instrument  lying  above  the 
telescope.  A  small  movable  tongue  or  finger,  which  can  be  raised  or 
lowered  by  means  of  a  screw  at  the  ocular  end  of  the  instrument,  is 
provided  for  the  purpose  of  changing  the  angle  of  the  catheters  as 
they  emerge  from  the  instrument.  Irrigating  cocks  are  provided 
with  both  styles  of  cystoscope. 

Instruments  may  also  be  obtained  with  which  it  is  possible  to 
employ  either  the  direct  or  indirect  methods  of  observation  and 
catheterization,   as  McCarthy's  composite  cystoscope,   which    has 


Fig.  734. — The  Bierhoff  cystoscope.  a,  Showing  the  instrument  with  the  tele- 
scope in  position  for  catheterization;  b,  showing  the  telescope  rotated  within  the 
sheath  to  facilitate  removal  of  the  instrument. 

both  indirect  and  direct  view  telescopes  and  an  indirect  double 
catheterizing  attachment,  and  the  universal  cystoscopes  of  Tilden 
Brown  and  Bransford  Lewis,  which  combine  in  one  instrument  direct 
and  indirect  observation  and  double  catheterization  by  either  the 
direct  or  indirect  method. 

While  the  choice  of  the  make  of  instrument  must  rest  with  the 
individual  operator,  there  is  no  doubt  that  in  the  majority  of  cases  it 
is  easier  to  catheterize  with  the  direct  view  instrument,  exceptions 
being  the  presence  of  intravesicular  hypertrophy  of  the  prostate  and 
a  trabeculated  bladder,  in  which  class  of  cases  the  indirect  view 
instrument  is  essential;  on  the  other  hand,  it  is  far  easier  to  locate 
the  ureteral  orifices  by  indirect  view. 


CATHETERIZING    THE    URETERS 


707 


The  catheters,  which  are  of  silk  elastic  material  about  24  inches 
(60  cm.)  long  and  5  to  7  French  in  size,  should  be  of  different  colors 
to  differentiate  them.  The  distal  end  is  either  blunt  or  ohve  pointed. 
Before  using,  it  should  be  seen  that  the  catheters  are  smooth  and  the 
eyes  perfect;  the  patency  of  the  catheters  should  also  be  tested  by 
injecting  water  through  them.  They  are  best  kept  at  full  length  in 
glass  tubes  plugged  with  cotton  at  either  end. 

For  the  purpose  of  recognizing  calculi  the  end  of  the  catheter  may 
be  dipped  in  melted  wax  (2  parts  of  dental  wax  and  i  part  of  ohve  oil) 
and  allowed  to  harden  in  the  air  (Fig.  735).  On  coming  in  contact 
with  a  stone  scratch  marks  will  be  produced  on  the  wax  tip.  The 
wax  catheters  can  only  be  used,  however,  with  the  direct  view  instru- 
ment and  to  avoid  scratching  the  wax  they  should  be  threaded 
through  the  instrument  from  the  vesical  end  backward. 


Fig.   735. — Wax-tipped  ureteral  catheter. 


In  addition  to  the  ureteral  catheters  an  irrigating  jar  or  a  Janet 
syringe  holding  3  to  4  ounces  (90  to  120  c.c.)  of  solution  and  a  soft- 
rubber  catheter  should  be  provided  for  irrigating  the  bladder. 

Illumination  for  the  cystoscope  may  be  obtained  from  a  six-  or 
eight-cell  battery  or  from  the  street  current  provided  a  controller  is 
employed. 

Asepsis. — The  cystoscope  should  be  well  cleaned  with  tincture  of 
green  soap  and  water  and  is  then  placed  in  a  i  to  20  carbohc  acid 
solution  or  95  per  cent,  alcohol,  or  it  may  be  sterilized  by  formahn. 
Before  using,  it  should  be  rinsed  oh  in  a  saturated  solution  of  boric 
acid.  The  catheters  are  sterilized  by  formalin  vapor  or  by  boihng 
for  one  or  two  minutes  in  plain  water,  care  being  taken  to  wrap 
them  separately  in  gauze  to  prevent  their  sticking  together  and  to 
place  them  at  full  length  in  the  sterilizer.  The  examiner's  hands  are 
carefully  sterilized  in  the  usual  way. 

Position  of  Patient. — The  patient  may  be  in  the  hthotomy  posi- 
tion with  the  buttocks  close  to  the  edge  of  the  table,  or  as  preferred 
by  some  operators  in  a  semirecumbent  posture.  The  table  should  be 
provided  with  uprights  which  are  surmounted  with  double  inchned 
rests  for  the  thighs  and  knees.     (See  Fig.  685) 

Anesthesia. — If  any  anesthesia  is  necessary,  local  anesthesia 
usually  suffices.     It  may  be  obtained  by  the  instillation  into  the  deep 


7o8 


THE  KIDNEYS  AND  URETERS 


urethra  of  a  small  quantity  of  a  2  per  cent,  solution  of  cocain  or  by 
filling  the  empty  bladder  with  5  ounces  (150  c.c.)  of  a  warm  o.i  per 
cent,  solution  of  cocain  to  which  is  added  20  drops  (1.25  c.c.)  of 
adrenalin.  This  must  be  retained  for  at  least  fifteen  to  twenty 
minutes.  Guyon's  method  may  also  be  employed  (see  page  662). 
In  some  few  cases  it  may  be  necessary  to  employ  general  anesthesia; 
for  children  general  anesthesia  should  always  be  used. 

Preparations  of  Patient. — The  external  genitals  should  be  cleansed 
with  soap  and  water  followed  by  a  i  to  5000  bichlorid  of  mercury 
solution.  The  bladder  is  then  emptied  and  thoroughly  irrigated 
with  a  saturated  solution  of  boric  acid  by  means  of  a  catheter  and  a 
large  syringe  or  through  the  sheath  of  the  cystoscope  if  the  instru- 
ment is  supplied  with  an  irrigating  cock,  until  the  fluid  returns  clear. 
Four  to  6  oimces  (120  to  180  c.c.)  of  a  saturated  boric  acid  or  normal 
salt  solution  are  then  injected  into  the  bladder  and  allowed  to  remain 
for  the  purpose  of  distention. 


Fig.  736. — Catheterization   by   the   direct   method,    showing   the   cystoscope   as 
introduced  and  with  the  vesical  end  deflected  toward  the  ureter. 


If  hemorrhage  from  the  bladder  is  sufficient  to  interfere  with  the 
operation,  a  i  to  3000  adrenalin  chlorid  or  i  to  15.000  silver  nitrate 
solution  should  be  injected  through  the  catheter  and  allowed  to 
remain  in  the  bladder  for  ten  to  fifteen  minutes  before  it  is  distended. 

Technic. — i.  Direct  Catheterization. — The  cystoscope  and  cathe- 
ters having  been  thoroughly  tested,  the  instrument,  well  lubricated 
with  glycerin  or  lubrichondrin  and  with  the  obturator  in  place,  is 
introduced  into  the  bladder.     The  obturator  is  then  removed  and  the 


CATHETERIZING    THE    URETERS 


709 


catheterizing  telescope  is  inserted  in  its  place,  after  which  the  light 
is  turned  on  and  the  ureteral  orifices  are  sought  for.  They  are  located 
at  the  upper  angles  of  the  trigone  about  3/4  inch  (2  cm.)  from  the 
median  line  and  i  inch  (2.5  cm.)  from  the  internal  opening  of  the 
urethra.  By  first  locating  the  apex  of  the  prostate  and  then  pushing 
the  instrument  in  about  i  inch  (2.5  cm.)  the  interureteric  line  which 
passes  between  the  two  ureters,  forming  the  base  of  the  trigone,  will 
come  to  view  and  if  this  is  traced  to  one  side  or  the  other  the  orifice 
of  the  ureter  will  be  recognized  in  the  lateral  angle  of  the  trigone.  It 
may  appear  either  as  a  slit  or  as  a  dimple  on  the  apex  of  a  papilla,  and, 
if  carefully  watched,  urine  will  be  seen  coming  from  it  in  intermittent 
spurts.  It  may  be  extremely  difi&cult  to  locate  the  ureter,  but  a 
careful  search  will  usually  reveal  it.  In  all  manipulations  of  the 
cystoscope  it  is  of  the  utmost  importance  to  employ  extreme  gen- 
tleness otherwise  bleeding  will  supervene  and  interfere  with  the 
examination. 


Fig.  737. — Catheterization  by  the  direct  method,  showing  the  heel  of  the  cysto- 
scope brought  close  to  the  mouth  of  the  ureter. 


With  the  direct  view  cystoscope  the  instrument  is  not  rotated 
about  an  axis,  but  the  beak  is  kept  constantly  pointing  upward  while 
the  vesical  end  is  turned  from  one  side  to  the  other  or  up  and  down 
as  the  case  may  be  (Fig.  736).  The  mouth  of  the  ureter  having  been 
located,  the  heel  of  the  cystoscope  is  brought  close  to  it  (Fig.  737)  and 
an  attempt  is  made  to  engage  the  catheter  in  its  lumen.     The  catheter 


7IO 


THE  KIDNEYS  AND  URETERS 


is  then  slowly  and  gently  threaded  up  the  ureter  to  the  desired  dis- 
tance (Fig.  738).  If  the  purpose  of  the  catheterization  is  simply  to 
withdrawurine  from  the  ureter,  the  catheter  is  introduced  3  to 4  inches 
(7.5  to  10  cm.);  in  exploring  the  ureter  for  stone  or  stricture,  or  to 
determine  whether  pus  has  its  origin  in  the  ureter  or  kidney  pelvis, 
the  catheter  should  be  passed  as  far  as  the  renal  pelvis — 13  to  15 
inches  (32  to  37  cm.).  If  less  than  11  inches  (27  cm.)  of  catheter 
can  be  inserted,  an  obstruction  must  be  inferred  (Braasch).  The 
other  ureter  is  located  and  catheterized  in  the  same  manner. 


Fig.   738. — Catheterization  by  the  direct  method,  showing  the  catheter  entering 

the  ureter. 


The  Hght  is  then  extinguished  and  the  catheterizing  attachment  is 
first  carefully  removed  and  then  the  sheath,  keeping  the  catheters  in 
position  in  the  ureter  by  threading  them  through  the  instrument  as 
it  is  withdrawn.  Unless  the  catheters  are  of  different  colors,  they 
should  be  labeled  'Meft"  or  "right"  in  order  to  distinguish  them. 
The  first  urine  that  flows  is  discarded  and  the  ends  of  the  catheters 
are  then  wiped  off  and  inserted  into  sterile  bottles  plugged  with 
cotton.  A  catheter  may  become  plugged  with  mucus,  blood  clots, 
or  pus.  If  so  about  15  TTt  (i  c.c.)  normal  salt  solution  may  be  in- 
jected through  it  by  means  of  a  syringe. 

From  2  to  4  ounces  (60  to  120  c.c.)  of  urine  are,  as  a  rule,  suffi- 
cient for  examination.  While  the  urine  is  being  collected,  the 
patient's  legs  should  be  released  from  the  crutches  holding  them  and 


CATHETERIZING    THE    URETERS 


711 


he  should  be  allowed  to  assume  as  comfortable  a  position  as  possible. 
At  the  completion  of  the  operation  the  catheters  are  carefully  re- 
moved and  the  bladder-  is  irrigated  with  a  saturated  solution  of  boric 
acid. 


Fig.  739. — Catheterization  by  the  indirect  method,   showing  the  cystoscope  in 

position. 


Fig.  740. — Catheterization  by  the  indirect  method,  the  catheter  being  pushed  into 
the  instrument  until  its  tip  passes  shghtly  beyond  the  ureteral  orifice. 

2.  Indirect  Catheterization. — The  instrument,  well  lubricated,  is 
introduced  into  the  bladder  and  is  then  rotated  completely  around  so 
that  its  beak  looks  posteriorly.     The  prostate  is  thus  located  and  by 


712  THE  KIDNEYS  AND  URETERS 

rotating  the  instrument  through  an  angle  of  30  to  45  degrees  the  lat- 
eral ridge  of  the  trigone  may  be  traced  running  backward  at  an  angle 


Fig.  741.— Catheterization  by  the  indirect  method,  showing  the  tip  of  the  catheter 
being  deflected  toward  the  ureteral  orifice  by  elevating  the  director. 


Fig.  742. — Catheterization  by  the  indirect  method,  showing  the  catheter  inserted 

in  the  ureter. 

from  the  prostate.     At  the  point  of  the  junction  of  this  ridge  with  the 
interureteric  line  will  be  found  the  ureteral  orifice.     It  should  be 


CATHETERIZING   THE    URETERS 


713 


remembered  that  with  this  form  of  instrmnent  the  image  will  appear 
inverted,  that  is,  the  prostate  will  appear  at  the  upper  portion  of  the 
field  instead  of  at  the  lower.  Having  located  the  ureteral  orifice  the 
instrument  is  brought  close  to  it  (Fig.  739)  and  the  catheter  is  pushed 
gently  forward  until  its  tip  passes  slightly  beyond  it  (Fig.  740).  The 
small  director  is  then  elevated  slightly  (Fig.  741)  and  the  catheter  is 
again  pushed  forward.  If  it  misses  the  orifice,  the  catheter  is  with- 
drawn a  Httle  and  a  second  attempt  made  to  introduce  it.  By 
pushing  the  catheter  forward  a  little  or  withdrawing  it  and  changing 
its  angle  of  deflection  slightly,  it  is  finally  introduced  into  the  ureter 
(Fig.  742).     The  other  ureter  is  then  located  and  the  catheter  is 


Fig.  743-  Fig.  744. 

Fig.  743. — Removal  of  the  sheath.  First  step,  showing  the  telescope  removed 
and  the  catheters  lying  loosely  in  the  sheath.  (After  Buerger,  Annals  of  Surgery, 
Feb.,  1909.) 

Fig.  744 — Removal  of  the  sheath.  Second  step,  showing  the  ocular  end  de- 
pressed and  carried  to  the  left  until  clear  of  the  catheters.  (After  Buerger, 
Annals  of  Surgery,  Feb.,   1909.) 

introduced  in  the  same  way.  The  catheterizing  telescope  is  then 
carefully  removed,  first  turning  the  deflector  down  and  extinguishing 
the  lamp.  It  is  sometimes  a  difficult  matter  to  remove  the  sheath  of 
the  cystoscope  and  still  leave  the  catheters  in  place  when  using  this 
form  of  instrument.  The  following  manipulations,  however,  de- 
scribed by  Buerger  {Annals  of  Surgery,  February,  1909),  simplify 
this  portion  of  the  operation: 

"  After  having  introduced  the  catheters  a  httle  higher  than  we 
would  if  the  instrument  were  to  remain  in  the  bladder,  and  after 


714 


THE  KIDNEYS  AND  URETERS 


removal  of  the  telescope,  the  following  movements  should  be  carried 
out:  first,  the  ocular  is  depressed  and  carried  a  little  to  the  left,  thus 
separating  the  beak  from  the  line  of  the  catheters  (Fig.  744);  second, 
the  whole  instrument  is  rotated  to  the  right  on  its  longitudinal  axis 
through  an  arc  of  190  degrees,  retaining  the  relative  position  just 
described,  thus  making  the  beak  point  upward  (Fig.  745);  third 
(still  in  the  same  plane,  with  the  ocular  a  little  to  the  left),  the  ocular 
is  raised  and  brought  back  to  the  median  line  in  order  to  bring  the 
convexity  of  the  beak  against  the  trigone  of  the  bladder  (Fig.  746); 
and  fourth,  the  sheath  is  removed,  its  inferior  aspect  being  made  to 
hug  the  posterior  wall  of  the  urethra." 

Removal  of  the  Bierhoff  instrument  is  comparatively  simple,  as 
it  is  arranged  so  that  the  telescope  may  be  rotated  within  the  sheath 
until  the  beak  points  upward  without  disturbing  the  catheters  (see 
Fig.  734)- 


Fig.  745. 

Fig.  745. — Removal  of  the  sheath.  Third  step,  showing  the  beak  being  turned 
upward.      (After  Buerger,  Annals  of  Surgery,  Feb.,  1909.) 

Fig.  746. — Removal  of  the  sheath.  Final  step,  the  beak  in  position  for  re- 
moval of  the  sheath.     (After  Buerger,     Annals  of  Surgery,    Feb.,  1909.) 


URETERAL  CATHETERIZATION  IN  THE  FEMALE 

Ureteral  catheterization  in  the  female  has  the  same  field  of 
usefulness  as  when  applied  to  the  male  (see  page  705).  In  addition, 
catheters  are  often  inserted  into  the  ureters  as  a  guide  to  their  posi- 
tion so  as  to  avoid  injuring  them  in  difficult  pelvic  operations. 
Catheterization  may    be  performed,  as  in  the  male,  by  means  of 


URETERAL  CATHETERZATION  IN  THE  FEMALE 


715 


one  of  the  catheterizing  cystoscopes,  the  method  of  performing 
which  requires  no  further  explanation  than  that  given  above,  or 
by  means  of  open  tubes  under  air  distention  after  the  method  of 
Kelly.     This  latter  method  requires  separate  description. 

Instruments. — The  ordinary  Kelly  speculum  with  illumination 
furnished  by  reflected  light  or  some  of  the  modifications  of  Kelly's 
tubes  with  the  Hght  at  the  distal  end  may  be  employed.  The  latter 
are  preferable. 

In  addition  there  will  be  required  a  cone-shaped  urethral  dilator, 
alligator-jaw-shaped  forceps,  a  residual  urine  evacuator,  Kelly's 
ureteral  searcher,  silk  flexible  catheters,  a  metallic  catheter,  and 
hard-rubber  flexible  sounds  (Fig.  747). 


Fig.  747. — Instruments  for  catheterizing  the  ureters  in  the  female,  i,  Open- 
tube  cystoscope;  2,  Kelly  urethral  dilator;  3,  residual  urine  evacuator;  4,  alligator- 
jawed  forceps;  5,  ureteral  searcher;  6,  metal  ureteral  catheter;  7,  flexible  ureteral 
catheters  with  stylets;  8,  ureteral  bougies. 

The  cystoscope,  alligator-jaw  forceps,  urethral  dilator,  and 
searcher  have  been  previously  described  (page  666). 

The  flexible  silk  catheters  are  made  in  two  lengths:  12  inches 
(30  cm.)  long  for  ordinary  ureteral  catheterization  and  20  inches 
(50  cm.)  long  for  catheterization  of  the  kidney  pelvis.  The  tips 
are  blunt  or  olivary  and  have  an  oval  eye  about  3/4  inch  (2  cm.) 
from  the  distal  end.  They  may  be  obtained  in  sizes  running  from 
1/16  to  1/8  inch  (1.5  to  3  mm.)  in  diameter.  A  wire  stylet  is  in- 
troduced within  the  catheter  to  furnish  it  with  the  necessary  stift'- 


•Jl6  THE    KIDNEYS    AND    LTiETERS 

ness  for  passage  into  the  ureter,  or  forceps,  such  as  Ashton's  (Fig. 
748),  may  be  employed  for  this  purpose.  As  an  aid  in  recognizing 
a  calculus  the  ends  of  the  catheters  may  be  wax- tipped  (see  Fig.  735). 
Metal  catheters  are  12  inches  (30  cm.)  long  and  i  '12  inch  (2  mm.) 
in  diameter  and  are  supplied  with  three  eyes  situated  back  of  the 
point  which  is  conical  in  shape  and  slightly  curved.  They  are 
employed  when  a  stricture  low  down  in  the  ureter  interferes  with  the 
passage  or  a  flexible  catheter. 


Fig.  748. — Ashton's  forceps  for  guiding  the  catheter  into  the  ureter.     (Ashton.) 

Solid,  flexible,  hard-rubber  bougies  are  employed  in  exploring  the 
ureters  or  dilating  strictures.  They  are  20  inches  (50  cm.)  long  and 
1/12  inch  (2  mm.)  in  diameter.  When  warmed  they  become  flexible 
and  in  this  state  may  be  passed  the  entire  length  of  the  ureter  without 
danger.  For  the  purpose  of  locating  stone  they  may  be  wax-tipped 
(Fig.  749). 


:i 


Fig.   749. — Wax-tipped  bougie.      (Ashton.) 

Asepsis. — Great  care  should  be  taken  to  observe  aU  aseptic  details. 
The  operator's  hands  should  be  thoroughly  cleansed,  and  precautions 
should  be  taken  not  to  allow  the  sterile  catheters  to  touch  the  table 
or  patient's  body  during  their  introduction.  Metal  instruments  and 
hard-rubber  bougies  are  sterilized  by  boiling  for  five  minutes  in  a  i 
per  cent,  soda  solution.  The  light  carrier  may  be  sterilized  by 
immersion  in  a  i  to  20  solution  of  carbolic  acid  followed  by  rinsing 
in  alcohol.  Silk  catheters  are  sterilized  by  formalin  vapor  or  are 
boiled  for  not  over  two  minutes  in  plain  water  and  are  then  placed  in 
cold  sterile  water  to  make  them  stift'.  Care  should  be  taken  when 
boihng  the  catheters  to  place  them  in  the  sterilizer  at  full  length  and 
to  wTap  them  separately  in  gauze  so  as  to  keep  their  surfaces  from 
becoming  glued  together. 

After  use  the  catheters  should  be  thoroughly  cleaned  inside  and 
outside  with  warm  water  and  tincture  of  green  soap  and  then  put 
away  at  full  length  in  a  glass  receptacle. 

Position  of  the  Patient. — As  for  cystoscopy  two  positions  are 
employed,  namely,  the  dorsal  elevated  and  the  knee-chest.     In  the 


URETERAL    CATHETERIZATION    IN    THE    FEMALE  717 

former  the  patient  lies  with  the  head  and  thorax  resting  on  the  table 
and  the  hips  elevated  8  to  12  inches  (20  to  30  cm.)  upon  a  cushion  so 
as  to  raise  the  pelvis  sufficiently  to  allow  the  bladder  to  distend  with  air 
when  the  cystoscope  is  in  place.  If  the  bladder  does  not  inflate  with 
the  patient  in  the  dorsal  position,  the  knee-chest  posture  is  employed. 
The  latter  position  is  usually  necessary  in  stout  people. 

Preparations  of  Patient. — It  should  be  seen  that  the  rectum  and 
bladder  are  empty  before  beginning  the  examination.  The  external 
genitals  are  then  washed  with  soap  and  water  followed  by  a  i  to 
5000  solution  of  bichlorid  of  mercury,  and  the  bladder  is  irrigated  with 
a  warm  saturated  solution  of  boric  acid  until  the  fluid  returns  clear. 
The  solution  is  then  all  drained  off  before  the  cystoscope  is  inserted. 

Anesthesia. — ^Local  anesthesia,  obtained  by  inserting  into  the  mea- 
tus a  small  pledget  of  cotton  saturated  with  a  2  per  cent,  solution  of 
cocain  and  allowing  it  to  remain  for  fi.ve  minutes,  is  generally  suffi- 
cient. In  extremely  nervous  patients  general  anesthesia  may  be 
required. 

Technic. — The  urethra  is  first  dilated  and  the  cystoscope  is  intro- 
duced in  the  manner  already  described  (page  669).  The  obturator  is 
then  removed,  when,  if  the  patient  is  in  the  proper  position,  air  rushes 
in  and  distends  the  bladder.  The  Hght  is  then  adjusted  and  a  search 
is  made  for  the  ureteral  orifices.  In  doing  this  it  is  well  to  first  with- 
draw the  instrument  until  the  mucous  membrane  of  the  internal 
urethral  orifice  begins  to  close  over  the  end  of  the  instrument,  and 
then  to  advance  it  1/2  to  3/4  inch  (i  to  2  cm.)  turned  either  to  the 
right  or  left  about  30  degrees  from  the  center  line  along  the  dark 
lateral  ridge  of  the  trigone.  The  distal  end  of  the  instrument  is  then 
brought  close  to  the  base  of  the  bladder  by  raising  the  handle  of  the 
cystoscope  if  the  patient  is  in  the  dorsal  position,  or  depressing  the 
handle  if  the  knee-chest  position  is  used.  By  moving  the  instrument 
carefully  about,  the  mouth  of  the  ureter  will  be  located  somewhere 
near  the  end  of  the  cystoscope.  It  may  appear  as  a  small  sHt  or  as  a 
distinct  hole  or  as  a  dark  point  in  the  bladder  mucous  membrane. 
If  it  is  not  readily  found,  the  speculum  should  be  directed  toward  its 
normal  location  and  a  careful  search  made  for  it  with  a  ureteral 
searcher  in  the  folds  of  mucous  membrane. 

Having  located  the  orifice,  the  end  of  the  cystoscope  is  brought 
close  to  it  and  the  catheter  is  introduced.  Metal  catheters  or  sounds 
are  not  difficult  to  introduce.  They  should  be  well  lubricated  and, 
while  the  cystoscope  is  maintained  in  position  with  the  left  hand,  they 
are  guided  by  means  of  the  right  hand  into  the  ureteral  orifice. 


7i8 


THE  KIDNEYS  AND  URETERS 


Flexible  catheters  may  be  introduced  in  two  ways,  either  by  the 
use  of  a  stylet  to  give  them  stiffness  or  by  the  aid  of  a  specially  made 
forceps,  such  as  Ashton's  (see  Fig.  748).  By  the  former  method  the 
catheter,  well  lubricated,  with  the  stylet  in  place,  is  gently  inserted  in 
the  same  manner  as  a  metal  catheter  into  the  mouth  of  the  ureter 
(Fig.  750).  The  stylet  is  then  withdrawn  and  the  catheter  is  pushed 
on  until  it  has  entered  the  desired  distance.  For  ordinary  purposes 
of  catheterization  this  will  be  3  or  4  inches  (7.5  to  10  cm.).     In  intro- 


FiG.   750. — Catheterization  of  the  ureter  in  the  female  by  means  of  a  flexible 
catheter  armed  with  a  stylet. 

ducing  these  flexible  catheters  care  must  be  observed  that  the  portion 
outside  the  cystoscope  does  not  become  contaminated  by  touching  the 
patient  or  the  table,  and  for  this  purpose  it  is  well  to  keep  this  part  of 
the  catheter  wrapped  in  sterile  gauze. 

If  it  is  desired  to  catheterize  both  ureters,  the  mouth  of  the  other 
one  is  then  located  and  the  catheter  introduced  in  the  same  manner. 
The  cystoscope  is  then  withdrawn  and  the  catheters  are  labeled  right 
and  left  to  distinguish  them.  After  wiping  the  ends  of  the  catheters, 
they  are  placed  in  two  small  sterile  bottles  plugged  with  sterile  cotton, 
and  about  2  to  4  drams  (8  to  15  c.c.)  of  urine  are  collected  from  each 
kidney  (Fig.  751). 


URETERAL    CATHETERIZATION    IN    THE    FEIIALE 


719 


Variation  in  Technic. — The  following   method,    devised   by 
Kelly,  for  collecting  urine  from  one  kidney  without  using  a  catheter 


Fig.  751. — Method  of  collecting  separate  urine  from  each  kidney.      (Ashton.) 


YiG,  7-2.— Kelly's  method   of  collecting  urine  from  a  kidney  without  using  a 

catheter.      (After  Kelly.) 

is  sometimes  employed  when  it  is  undesirable  to  introduce  a  catheter 
into  the  ureter  for  fear  of  carrying  an  infection  from  the  bladder  or 


720  THE   KIDNEYS   AND   URETERS 

from  other  causes.  Briefly,  it  consists  in  placing  the  patient  in  the 
knee-chest  posture,  introducing  into  the  bladder  a  speculum  with  the 
end  cut  on  the  slant,  and  exposing  to  view  the  ureteral  orifice  from 
which  it  is  desired  to  obtain  a  specimen  of  urine.  The  orifice  of  the 
ureter  is  then  wiped  clean  and  the  speculum  is  held  close  against  the 
bladder  wall  so  that  the  urine  escapes  into  the  speculum  whence  it  is 
collected  by  means  of  a  small  glass  graduate  (Fig.  752).  In  this  way 
often  in  a  short  time  sufiicient  urine  may  be  collected  for  purposes  of 
examination. 

PYELOMETRY 

By  distending  the  renal  pelvis  with  fluid  its  capacity  may  be  meas- 
ured, and  from  this  it  may  be  determined  whether  the  pelvis  is  normal, 
contracted,  or  dilated.  The  test  is  based. upon  the  fact  that  if  the 
kidney  pelvis  is  overdistended  an  artificial  renal  colic  is  produced.  A 
normal  pelvis  will  hold  from  i  1/4  to  4  drams  (5  to  15  c.c.)  of  fluid 
without  pain.  According  to  Braasch  if  the  renal  pelvis  has  a  capa- 
city of  less  than  50  TTt  (3  c.c.)  it  indicates  irritability  or  a  con- 
traction generally  due  to  stone,  tumor,  acute  or  chronic  pyelitis,  or 
spasm;  a  pelvis  allowing  distention  up  to  i  ounce  (30  c.c.)  may  be 
found  in  neurotic  subjects,  the  condition  being  explained  by  the  pres- 
ence of  a  hysterical  anesthesia;  while  a  capacity  of  10  drams  (40 
c.c.)  and  over  indicates  hydronephrosis. 

Instruments. — A  direct  or  indirect  catheterizing  cystoscope, 
ureteral  catheters,  catheter  and  syringe  for  irrigating  the  bladder,  a 
small  syringe  with  a  capacity  of  2  1/2  (10  c.c.)  with  a  nozzle  that  will 
fit  the  end  of  the  ureteral  catheter  as  the  Record  syringe,  and  a  glass 
measuring  graduate  will  be  required. 

Asepsis. — See  under  ureteral  catheterization  (pages  707,  716). 

Solution  Used. — A  2  per  cent,  boric  acid  solution  colored  with  a 
drop  or  two  of  methylene  blue  is  employed. 

Temperature. — The  solution  should  be  at  a  temperature  of  about 
100°  F.  (38°  C). 

Position  of  Patient. — Same  as  for  ureteral  catheterization  (pages 
707,  716). 

Anesthesia. — (Seepages  707,  717). 

Preparation  of  Patient. — Same  as  for  ureteral  catheterization 
(pages  708,  717). 

Technic— A  catheter  of  sufficient  size  to  occlude  the  ureter  and 
prevent  the  escape  of  the  solution  beside  it  is  introduced  into  the 


SEGREGATION   OF   URINE  72 1 

ureter  of  the  affected  side  as  far  as  the  pelvis  (see  ureteral  catheteri- 
zation pages  708,  717).  The  colored  solution  is  then  injected  into 
the  catheter  while  the  operator  notices  through  the  cystoscope  if  any 
of  it  leaks  back  into  the  bladder;  if  not,  the  injection  is  slowly  con- 
tinued until  colicky  pain  is  produced  in  the  region  of  the  kidney, 
showing  that  the  pelvis  is  distended.  The  quantity  injected  indicates 
the  capacity  of  the  pelvis. 

SEGREGATION  OF  URINE 

Special  instruments,  known  as  segregators,  which  separate  the 
bladder  into  two  halves  through  the  formation  of  an  artificial  dam, 
may  be  employed  to  collect  the  urine  separately  from  the  kidneys 
when  a  catheter  cannot  be  passed  into  the  ureter  or  ureteral  catheter- 
ization is  contraindicated.  They  are  easier  to  employ  than  the  ure- 
teral catheter  and  with  their  use  there  is  no  danger  of  carrying  infec- 
tion into  the  ureters,  but,  on  the  other  hand,  they  are  not  so  accurate, 
as  an  incomplete  watershed  may  be  formed  allowing  the  urine  from 
the  two  sides  to  mingle,  and  the  introduction  of  the  instruments  may 
incite  vesical  bleeding  and  give  misleading  results.  Again,  if  the 
bladder  is  diseased,  the  urine  obtained  is,  of  course,  contaminated  and 
it  is  not  possible  to  determine  whether  the  source  of  blood  or  pus  is 
the  bladder,  ureter,  or  kidney.  If  the  bladder  is  very  irritable  or 
bleeds  easily,  as  is  the  case  in  the  presence  of  acute  cystitis,  vesical 
calculus,  tumors,  and  prostatic  hypertrophy,  a  segregator  should  not 
be  used.  In  healthy  bladders,  however,  segregation  properly  per- 
formed is  fairly  reliable.        ' 

Instruments. — There  are  several  types  of  urine  separators  among 
which  may  be  mentioned  the  instruments  of  Harris  and  Luys. 

The  Harris  segregator  (Fig.  753)  consists  of  two  catheters  having 
a  common  sheath  except  at  the  distal  and  proximal  ends.  The  intra- 
vesical ends  when  in  contact  form  a  cylinder  with  a  double  curve  and 
are  supplied  with  numerous  small  eyes  which  lead  to  the  interior  of 
the  catheter.  The  extravesical  portions  end  in  curved  metal  tubes  to 
which  are  connected  by  means  of  pieces  of  rubber  tubing  two  aspirat- 
ing bottles.  A  long  lever,  connected  to  the  shaft  of  the  instrument  by 
means  of  a  fulcrum  and  spring,  which  is  inserted  into  the  rectum  or 
vagina  for  the  purpose  of  raising  up  the  bladder  wall  in  the  mid-line 
in  the  form  of  a  dam,  is  also  provided. 

Luys'  instrument(Fig.  754)  consists  of  two  catheter  tubes  separated 
by  a  metal  partition,  the  vesical  end  of  which  has  a  Benique  form  of 


722 


THE  KIDNEYS  AND  URETERS 


curve.  On  the  concave  side  of  the  intravesicalportion  is  a  small  chain 
covered  with  a  thin  india-rubber  membrane,  so  arranged  that  after  the 
instrument  is  within  the  bladder  by  turning  a  screw  at  the  proximal 
end  of  the  instrument  the  rubber  membrane  is  made  to  partition  the 


Fig.  753. — The  Harris  segregator.     (Ashton.) 

bladder  into  two  halves.  Near  the  proximal  end  are  two  discharge 
tubes  which  empty  into  small  bottles.  In  males  this  instrument 
causes  less  discomfort  than  does  the  Harris  segregator. 

Asepsis. — The  instruments  and  the  bottles  for  collecting  the  urine 
should  be  sterilized  by  boiling  for  five  minutes,  and  the  operator's 
hands  are  cleansed  as  for  any  operation. 


Fig.  754. — The  Luys  segregator. 

Position  of  Patient. — In  using  the  Harris  instrument  the  patient 
lies  flat  on  the  back  with  the  feet,  hips,  and  head  on  a  level  and  with 
the  thighs  flexed. 

The  same  position  is  employed  in  inserting  the  Luys  instrument, 
but,  when  the  instrument  is  in  the  bladder,  the  patient  is  elevated  to  a 
semi-sitting  position. 


SEGREGATION    OF    URINE 


723 


Preparations  of  Patient. — The  rectum  should  be  empty.  The 
external  genitals  are  cleansed  with  soap  and  water  followed  by  a  i 
to  5000  solution  of  bichlorid  of  mercury.  The  urethra  is  irrigated 
with  a  I  to  5000  solution  of  potassium  permanganate.  The  bladder  is 
emptied  by  means  of  a  catheter  and  is  then  irrigated  with  a  saturated 
solution  of  boric  acid  or  sterile  water.  About  5  ounces  (150  c.c.) 
of  solution  is  left  in  place  when  using  the  Harris  instrument  to  permit 
manipulation  of  the  instrument,  less  distention  being  necessary  with 
the  Luys  instrument. 

Anesthesia. — Local  anesthesia  may  be  required  if  the  urethra  or 
bladder  are  hyperesthetic. 

Technic. —  i.  Harris^  Method. — The  instrument,  closed  so  the 
catheters  form  a  continuous  tube,  is  well  lubricated  and  is  introduced 


Fig.  755. — Segregation  of  urine  by  means  of  the  Harris  segregator.     First  step, 
instrument  in  position  in  the  bladder.      (Ashton.) 

into  the  bladder  until  its  beak  lies  just  within  the  vesical  neck  (Fig. 
755).  The  proximal  ends  are  then  rotated  outward  so  that  the  vesical 
ends  are  made  to  lie  on  either  side  of  the  ureteral  orifices  and  are  fixed 
in  this  position  by  the  small  spring  at  the  proximal  end  of  the  instru- 
ment (Fig.  756).  The  long  lever,  well  lubricated,  is  then  introduced 
into  the  rectum  of  the  male  or  the  vagina  of  the  female  and  is  secured 
by  a  clamp  to  the  sheath  of  the  catheters.  By  means  of  a  spiral  spring 
the  rectal  or  vaginal  end  is  forced  upward  causing  a  longitudinal  ridge 
of  bladder  wall  to  be  formed  in  the  mid-line  between  the  two  ureteral 
orifices  with  the  end  of  each  catheter  lying  at  the  bottom  of  the  corre- 
sponding compartment  of  the  bladder.  The  fluid  left  in  the  bladder 
is  then  allowed  to  escape  from  each  catheter  until  it  has  all  been 
drained  off.     The  aspirating  apparatus  is  then  attached  and  the  urine 


724 


THE  KIDNEYS  AND  URETERS 


is  gently  sucked  out  of  the  viscus  from  time  to  time  by  means  of  the 
suction  bulb  and  is  collected  in  two  sterile  bottles  (Fig.  757).  The 
instrument  must  be  left  in  place  about  half  an  hour  to  collect  suillicient 


Fig.  756. — Segregation  of  urine  by  means  of  the  Harris  segregator.     Second  step, 
vesical  ends  of  the  instrument  separated.      (Ashton.) 


Fig.  757. — Segregation  of  urine  by  means  of  the  Harris  segregator.     Third  step, 
the  instrument  in  place.      (Ashton.) 

urine  for  examination.     Care  must  be  taken  to  avoid  too  vigorous 
aspiration  or  hemorrhage  will  be  incited. 

At  the  completion  of  the  operation  the  lever  is  detached,  the  cath- 
eters are  folded  back   in  place,    and   the  instrument  is   carefully 


THE    FUNCTIONAL    CAPACITY    OF    THE    KIDNEYS 


725 


removed,  following  which  the  bladder  is  irrigated  with  a  saturated 
solution  of  boric  acid. 

2.  Liiys^  Method. — The  rubber  dam  is  first  carefully  examined  to 
see  if  it  is  intact.  The  instrument,  well  lubricated,  is  then  introduced 
in  the  same  manner  one  would  insert  a  sound,  depressing  the  handle 
well  between  the  thighs  as  soon  as  the  tip  enters  the  prostatic  urethra 
so  as  to  carry  the  curved  portion  into  the  bladder.  As  soon  as  the 
instrument  is  well  within  the  bladder,  the  patient  is  raised  to  a  semi- 
sitting posture  and  the  diaphragm  is  raised,  carefully  keeping  the 
instrument  exactly  in  the  median  line.  The  handle  of  the  instrument 
is  then  elevated  until  resistance  shows  that  the  intravesical  portion  is 
in  contact  with  the  base  of  the  bladder.     This  should  be  confirmed 


Fig.  758. — Showing   the  method  of  using  the  Luys  segregator. 

by  vaginal  or  rectal  palpation.  After  all  solution  has  been  drained 
from  the  bladder,  the  urine,  as  it  trickles  into  the  bladder,  is  carried 
off  by  a  catheter  on  each  side  and  is  collected  in  the  small  tubes  at  the 
proximal  ends  of  the  instrument  (Fig.  758). 

At  the  completion  of  the  operation  the  diaphragm  is  lowered  and 
the  instrument  is  withdrawn.  This  is  followed  by  a  vesical  irrigation 
of  boric  acid. 

DETERMINATION  OF  THE  FUNCTIONAL  CAPACITY  OF  THE 

KIDNEYS 

By  the  functional  capacity  of  the  kidney  is  understood  the  ability 
of  that  organ  to  perform  its  excretory  functions.  In  surgical  work 
it  is  always  important  to  determine  whether  the  kidneys  are  doing 
normal  excretory  work,  but,  unless  a  severe  operation  is  to  be  under- 


y26  THE  KIDNEYS  AND  URETERS 

taken,  a  careful  urinalysis,  including  the  total  daily  amount  of  urine, 
the  daily  excretion  of  urea,  etc.,  is  sufficient.  When  the  removal  of 
one  kidney  is  contemplated,  however,  in  addition  to  determining 
whether  the  two  kidneys  are  functionating  properly,  the  functional 
capacity  of  each  kidney  should  be  determined  as  far  as  possible.  A 
variety  of  procedures  with  this  in  view  have  been  devised.  These 
include  (i)  estimation  of  the  amount  of  urea  excreted,  (2)  induc- 
ing artificial  glycosuria  by  phloridzin,  (3)  the  methylene-blue  and 
indigo-carmin  tests,  (4)  the  phenolsulphonephthalein  test,  (5)  cryos- 
copy  of  the  blood  and  urine,  and  (6)  the  experimental  polyuria  test. 

While  these  tests  are  very  valuable,  none  of  them  are  infallible,  for, 
though  they  demonstrate  which  kidney  is  functionating  best,  they 
do  not  absolutely  prove  that  a  particular  kidney  is  healthy  and  cap- 
able of  doing  sufficient  excretory  work  after  removal  of  its  mate. 

The  Urea  Test. — The  average  daily  amount  of  urea  excreted  in 
health  amounts  to  from  250  to  450  grains  (16  to  29  gm.).  In  the 
presence  of  one  diseased  kidney,  if  it  is  found  on  repeated  examina- 
tions that  the  average  total  daily  amount  is  not  reduced  to  below  250 
grains  (16  gm.),  it  is  evident  that  the  sound  kidney  is  compensating 
for  the  other's  inefficiency.  Collection  of  the  separate  urine  from 
each  kidney  by  ureteral  catheterization  and  estimation  of  the  amount 
of  urea  in  each  specimen  will,  however,  show  exactly  the  proportion 
of  work  each  kidney  performs. 

The  Phloridzin  Test. — This  test  depends  upon  the  property  of 
the  healthy  kidneys  to  form  sugar  from  phloridzin.  The  bladder  is 
first  emptied  and  then  i6Tn,  (i  c.c.)  of  a  i  to  200  solution  of  phloridzin 
are  injected  into  the  buttock.  If  the  kidneys  are  healthy,  glycosu- 
ria should  appear  within  fifteen  minutes  to  half  an  hour  after  the  ad- 
ministration of.  the  phloridzin  and  should  persist  for  about  two  to 
four  hours.  Delay  in  its  appearance  or  the  excretion  of  only  small 
amounts  of  sugar  points  to  renal  insufficiency,  while  an  entire  absence 
of  sugar  indicates  that  the  kidneys  are  seriously  affected.  If  the 
functional  activity  of  each  kidney  is  to  be  determined,  a  catheter  is 
placed  in  each  ureter  and  the  relative  proportion  of  sugar  in  the 
separate  specimens  of  urine  thus  obtained  is  estimated. 

Methylene=blue  and  Indigo=carmin  Tests. — Another  method 
of  testing  the  functional  activity  of  the  kidneys  is  to  inject  drugs, 
such  as  methylene  blue  or  indigo-carmin,  which  color  the  urine  after 
entering  the  circulation.  For  this  purpose  i6Tn.  (i  c.c.)  of  a  5  per 
cent,  solution  of  methylene  blue  is  given  hypodermically  or  6oTn, 
(4  c.c.)  of  a  4  per  cent,  solution  of  indigo-carmin  is  injected  intra- 


THE   FUNCTIONAL   CAPACITY   OF   THE   KIDNEYS  727 

muscularly.  If  the  kidneys  are  normal,  upon  cystoscopic  examina- 
tion within  half  an  hour  after  administration  of  the  methylene  blue 
and  within  ten  to  twelve  minutes  after  the  administration  of  the 
indigo- carmin,  stained  urine  will  be  seen  escaping  from  the  ureteral 
orifices. 

It  is  claimed  for  these  tests  that  if  the  coloring  of  the  urine  is  delayed 
or  its  intensity  lessened  it  tends  to  show  that  there  is  some  impair- 
ment of  the  renal  function. 

The  Phenolsulphonephthalein  Test. — In  igioRowntree  and 
Geraghty  proposed  a  new  colorimetric  test  for  estimating  the  renal 
function  by  using  phenolsulphonephthalein.  As  this  drug  is  very 
rapidly  and  almost  exclusively  eliminated  from  the  body  by  the 
kidneys,  the  test  is  one  of  the  most  delicate  and  reliable  for  determin- 
ing the  functional  efficiency  of  the  kidneys.  When  the  kidney  func- 
tion is  not  impaired,  the  drug  is  present  in  the  urine  within  five  to 
ten  minutes  after  a  subcutaneous  injection,  from  40  to  60  per  cent,  of 
it  being  excreted  within  the  first  hour  and  from  20  to  25  per  cent, 
during  the  second  hour.  After  an  intramuscular  injection,  the  drug 
appears  in  the  urine  in  about  the  same  time  as  after  a  subcutaneous 
injection,  but  from  5  to  10  per  cent,  more  is  eliminated  during  the  first 
hour.  Following  an  intravenous  injection,  the  drug  appears  in  the 
urine  in  from  three  to  live  minutes,  and  from  35  to  45  per  cent,  of  it 
is  eliminated  within  the  first  half  hour  and  63  to  80  per  cent,  during  . 
the  first  hour.  The  quantity  of  the  drug  eliminated  during  a  given 
time  indicates  the  excretory  capacity  of  the  kidneys,  that  is,  the 
quantity  will  be  diminished  according  to  the  amount  of  kidney  im- 
pairment present. 

Technic. — ^Twenty  minutes  to  half  an  hour  before  making  the  test 
the  patient  is  given  two  or  three  glasses  (300-400  c.c.)  of  water  in 
order  to  assure  a  free  urinary  secretion.  Under  the  usual  aseptic 
precautions  the  patient  is  catheterized,  the  catheter  being  left  in  the 
empty  bladder.  Sixteen  minims  (i  c.c.)  of  the  standard  alkaline 
solution  of  phenolsulphonephthalein  containing  6  mg.  (approxi- 
mately yV  gr.)  of  the  drug  are  then  injected  subcutaneously,  intra- 
muscularly, or  intravenously^  and  the  time  of  injection  is  noted. 
The  urine  is  allowed  to  flow  into  a  test-tube  containing  a  drop  of  a  25 
per  cent,  solution  of  sodium  hydroxid  and  the  time  of  the  first  faint 
pinkish  tinge  is  noted.  The  catheter  is  now  withdrawn,  the  patient 
being  required  to  urinate  into  a  receptacle  at  the  end  of  an  hour  after 

^Rowntree  and  Geraghty  (Journal  of  American  Medical  Association,  Sept.  2, 
191 1)  advocate  for  general  use  the  intramuscular  injection  in  the  lumbar  muscles. 


728  THE   KIDNEYS    AND   URETERS 

the  first  appearance  of  the  drug  and  in  a  second  receptacle  at  the 
of  the  second  hour.  In  the  presence  of  urinary  obstruction,  the 
catheter  is  left  in  the  bladder,  the  hourly  specimens  being  separately 
collected.  Twenty-five  per  cent,  solution  of  sodium  hydroxid  is  now 
added  to  the  urine  in  sufiicient  quantity  to  render  it  strongly  alkaline 
and  bring  out  the  characteristic  color — a  brilhant  purple  red. 

To  determine  the  amount  of  dye  present  a  Duboscq  colorimeter  or 
a  modified  Hellige  hemoglobinometer  is  employed.  The  solution  con- 
taining the  urine  is  diluted  with  sufficient  distilled  water  to  make  i 
quart  (i  liter)  and  after  thoroughly  mixing  a  small  filtered  portion  is 
compared  with  a  standard  in  the  colorimeter.  A  simpler  and  fairly 
accurate  method  is  to  prepare  a  series  of  standard  solutions  in  test- 
tubes  containing  5,  10,  15,  20  per  cent,  etc.,  of  the  drug  up  to  60  per 
cent.,  and  then  selecting  the  standard  tube  which  matches  the  color 
of  the  diluted  urinary  specimen. 

To  determine  the  functional  efficiency  of  each  kidney,  the  ureters 
are  catheterized  and,  as  soon  as  the  urine  flows  freely,  the  drug  is 
injected.  The  time  of  injection  is  recorded  and  the  collection  of  urine 
from  each  side  is  continued  for  one  hour  from"  the  time  of  the  first 
appearance  of  the  drug.  If  the  drug  is  given  intravenously  the  urine 
need  only  be  collected  for  fifteen  minutes  after  the  appearance  of 
the  drug.  The  quantity  excreted  in  each  specimen  is  then  estimated 
as  described  above. 

Cryoscopy. — Cryoscopy  is  the  determination  of  the  freezing- 
point  of  a  liquid  compared  to  that  of  distilled  water.  The  underlying 
principle  of  this  test  is  that  fluids  containing  a  small  amount  of  soUd 
material  give  a  high  freezing-point  while  liquids  with  greater  concen- 
tration freeze  at  a  lower  temperature.  Applied  to  the  blood  and 
urine,  cryoscopy  is  valuable  in  determining  the  renal  activity  of  the 
kidneys  and  in  some  cases  may  be  of  prognostic  value  when  renal 
impairment  exists.  For  example,  if  the  kidneys  are  doing  an  insuffi- 
cient amount  of  excretory  work,  there  will  be  an  accumulation  of 
solid  material  in  the  blood  which  will,  therefore,  freeze  at  a  lower 
temperature  than  normal,  and  at  the  same  time  the  urine  in  such  a 
case,  through  impairment  of  the  power  of  the  kidneys  to  eliminate 
properly,  will  give  a  higher  freezing-point  than  normal. 

The  freezing-point  of  normal  blood  is  0.56°  C.  below  that  of  dis- 
tilled water.  In  weakened  anemic  individuals,  however,  it  may  rise 
to  —0.55°  C.  or  even  as  high  as  —0.53°  C.  or  —0.52°  C.  If  cryo- 
scopy of  the  blood  gives  a  freezing-point  below  —0.56°  C,  it  is 
regarded  as  indicating  some  impairment  of  the  renal  function  with 


THE    FUNCTIONAL    CAPACITY    OF    THE    KIDNEYS  729 

retention  of  waste  products  in  the  blood.  According  to  Kummell,  if 
the  freezing-point  of  blood  falls  to  —0.60°  C.  it  indicates  such  a  degree 
of  renal  impairment  that  nephrectomy  is  contraindicated. 

Cryoscopy  of  the  urine  is  of  less  value  than  when  the  test  is  applied 
to  the  blood.  Healthy  urine  freezes  at  —0.9°  C.  to  —2°  C,  and  if 
the  freezing-point  is  higher  than  —0.9°  C.  it  is  considered  to  be  in- 
dicative of  insufficient  renal  activity.  Cryoscopy  of  urine  collected 
separately  from  each  kidney  by  ureteral  catheterization  will  give 
more  information  than  when  the  test  is  applied  to  the  bulk  of 
urine. 

To  carry  out  this  test  2  1/2  drams  (10  c.c.)  of  blood  and  urine  are 
required.  For  comparative  examination  the  two  should  be  collected 
at  the  same  time,  the  former  by  venous  puncture  (page  250)  and  the 
latter  by  ureteral  catheterization  (page  705). 

For  the  technic  of  cryoscopy,  which  requires  a  considerable 
amount  of  skill  to  properly  carry  out,  the  reader  is  referred  to  some  of 
the  manuals  on  clinical  laboratory  methods. 

Experimental  Polyuria  Test.^ — Still  another  method  of  esti- 
mating the  functional  activity  of  the  kidneys  is  that  known  as  the 
experimental  polyuria  test,  devised  by  Albarran,  which  consists 
essentially  in  obtaining  the  urine  from  each  kidney  when  the  patient 
is  dry  and  comparing  the  two  specimens  and  then  having  the  patient 
drink  a  large  quantity  of  water  and  noting  the  effect  upon  the  activity 
of  the  two  kidneys. 

The  test  is  based  upon  the  following  laws:  First,  a  diseased  kidney 
has  a  more  uniform  function  than  a  healthy  one,  and  the  more 
extensively  its  parenchyma  is  destroyed  the  less  will  its  function  vary 
from  time  to  time;  second,  when  one  kidney  alone  is  diseased  or  is 
more  diseased  than  the  other,  if  the  urinary  function  is  disturbed,  its 
function  is  less  modified  than  the  other.  In  other  words,  if  an 
increased  excretory  demand  is  placed  upon  the  kidneys  through  the 
ingestion  of  large  quantities  of  water  and  the  urine  is  collected  sepa- 
rately, the  less  diseased  organ  should  show  a  greater  increase  in  activ- 
ity, manifested  by  the  excretion  of  a  larger  total  amount  of  fluid  and 
solids,  though  the  percentage  of  solids  will  be  diminished,  while  the 
disea,sed  kidney  will  show  a  relatively  small  or  no  increase  in  activity. 
The  test  thus  becomes  of  value  in  determining  which  kidney  is  func- 
tionating best  and  the  power  of  each  to  accommodate  itself  to 
increased  demands  for  excretory  work. 

Technic. — The  patient  should  not  have  eaten  anything  for  four 
hours  or  taken  any  liquids  for  three  hours.     A  single  catheter  is  placed 


73 O  THE  KIDNEYS  AND  URETERS 

in  one  ureter  and  the  urine  from  the  other  side  is  collected  by  means  or 
a  small  catheter  passed  into  the  bladder.  The  urine  which  flows  fof 
the  first  ten  or  fifteen  minutes  is  discarded  in  order  to  permit  the  re- 
flex polyuria  which  may  follow  the  introduction  of  the  ureteral 
catheter  to  subside,  and  the  urine  that  then  flows  is  collected  for  half 
an  hour.  This  is  saved  for  comparison  with  specimens  taken  after 
the  administration  of  the  fluid.  At  the  end  of  half  an  hour  the  patient 
is  given  two  to  three  glasses  of  mineral  water  and  the  urine  is  collected 
separately  and  examined  at  half  hour  intervals  for  one  and  a  half 
hours.  Not  only  is  the  total  quantity  of  urine  noted,  but  the  speci- 
mens are  tested  as  to  the  freezing-point,  quantity  of  urea  and  sodium 
chlorid,  and,  if  phloridzin  has  been  given,  the  amount  of  sugar  is 
estimated. 

SKIAGRAPHY 

The  X-rays  are  of  the  greatest  aid  in  the  diagnosis  of  ureteral  and 
renal  calculi.  A  good  picture  will  give  positive  information  as  to  the 
position  of  a  calculus,  that  is,  whether  it  is  located  in  the  ureter  or 
kidney  and  w^ill  demonstrate  the  number  and  size,  as  well  as  the 
position  of  the  kidneys.  In  order  to  interpret  the  results  of  the  X-ray 
correctly  the  plate  should  show  the  following  anatomic  landmarks. 
The  eleventh  and  twelfth  ribs,  the  transverse  processes  of  the  verte- 
brae, the  crests  of  the  ilia,  and  the  psoas  muscle.  If  these  points  are 
shown,  the  position  of  a  calculus  may  be  determined  with  accuracy. 
The  shadows  cast  by  tumors,  fecal  concretions,  calcified  retroperit- 
oneal glands,  buried  sutures  which  have  become  calcified,  phleboliths, 
foreign  bodies  in  the  intestines,  the  thickened  tip  of  an  appendix,  etc., 
are  sometimes  wrongly  interpreted  as  calculi.  Such  errors  may  be 
avoided  if  a  catheter  filled  with  a  30  per  cent,  bismuth  paste  or  a 
catheter  in  which  a  lead  wire  stylet  has  been  placed  is  inserted  into 
the  ureter  and  renal  pelvis,  and  an  X-ray  is  then  taken.  The  shadow 
of  a  calculus  will  be  shown  to  be  in  close  relation  to  that  produced  by 
the  wire  in  the  ureter.  Thus,  while  a  positive  picture  can  usually  be 
taken  as  proof  of  the  presence  of  a  calculus,  this  cannot  always  be 
said  of  the  negative  evidence  furnished  by  an  X-ray.  It  must  be 
remembered  that  great  thickness  of  the  abdominal  wall  may  interfere 
with  the  success  of  a  picture  and  that  the  chemical  composition  of  the 
stone  is  also  an  important  element,  for  while  oxalate  and  phosphate 
stones  give  a  deep  shadow,  those  composed  of  uric  acid  furnish  but 
faint  shadows  and  may  escape  recognition.     In  all  cases  to  obtain  a 


EXPLORATORY    INCISION  73 1 

successful  picture  it  is  absolutely  essential  that  the  stomach  be  empty 
and  the  bowels  be  thoroughly  cleared  by  a  purge  given  the  night 
before  and  an  enema  the  morning  of  the  examination. 

Pyelography. — This  consists  in  the  injection  of  an  opaque  fluid 
into  the  ureter  and  renal  pelvis  followed  by  an  immediate  radiograph. 
This  method  of  diagnosis  is  of  the  greatest  value  in  demonstrating  the 
extent  and  character  of  dilatations  of  the  renal  pelvis  and  ureter, 
distortions  of  the  pelvis  by  tumors  or  stones  and  of  the  ureter  by  the 
presence  of  stones  or  strictures. 

A  10  to  15  per  cent,  solution  of  collargol  or  a  50  per  cent,  solution 
of  argyrol  are  the  most  frequently  employed.  Kelly  and  Lewis 
advocate  a  5  per  cent  silver  iodid  emulsion.  The  catheter  is 
inserted  into  the  renal  pelvis  and  the  contents  are  allowed  to  run  off. 
A  quantity  of  the  warmed  opaque  silver  solution  sufficient  to  distend 
the  renal  pelvis  is  then  allowed  to  slowly  flow  in  under  the  force  of 
gravity.  The  quantity  of  fluid  used  will  depend  upon  the  size  of  the 
pelvis  previously  determined  by  pyelometry  (see  page  720)  or  by  the 
production  of  pain  when  the  pelvis  is  distended.  To  study  the 
ureter  the  catheter  is  partly  withdrawn  so  that  the  ureter  may  be 
filled  up  and  distended  by  the  solution.  The  catheter  is  then 
plugged  to  prevent  the  escape  of  the  solution  and  the  opposite  side 
is  similarly  injected,  a  radiograph  being  taken  immediately.  The 
plugs  are  finally  removed  from  the  catheters  and  the  solution  is 
allowed  to  drain  off.  To  aid  in  removing  the  solution  it  is  well  to 
induce  a  polyuria  by  giving  the  patient  a  glass  of  water  to  drink  at 
the  completion  of  the  operation. 

EXPLORATORY  INCISION 

In  cases  of  contemplated  nephrectomy  where  other  means  of 
diagnosis  fail  to  give  satisfactory  results,  an  exploratory  operation 
will  determine  the  exact  condition  of  the  second  kidney.  The  kidney 
requiring  removal  is  first  exposed  and  thoroughly  explored.  If  its 
removal  seems  indicated,  it  is  replaced  for  the  time  being  and  the 
kidney  supposed  to  be  healthy  is  then  cut  down  upon  by  a  lumbar 
incision,  the  capsule  is  incised,  and  the  organ  is  palpated  and  if  neces- 
sary inspected.  If  it  is  found  to  be  healthy,  the  wound  is  closed  and 
the  other  kidney  may  then  be  removed.  Should,  however,  such 
exploration  reveal  serious  disease  of  the  second  kidney,  nephrectomy 
is  contraindicated. 


732 


THE  KIDNEVS  AXD  URETERS 


Therapeutic  Measures 

MEDICATION  OF  THE  RENAL  PELVIS  AND   CJRETERS 

'Lavage  of  the  kidney  pelvis  and  ureter  has  been  employed  with 
considerable  success  by  Kelly  and  others  in  treating  subacute  and 
chronic  affections  of  the  kidney  pelvis  and  ureter.  The  procedure  is 
not  difhcult  for  one  skilled  in  the  passage  of  the  ureteral  catheter,  and 
properly  performed  seems  to  be  without  danger.  It  is  not  a  suitable 
method  of  treatment,  however,  in  acute  infections,  and  in  chronic 
cases,  even,  other  measures  should  be  hrst  given  a  trial. 


Fig.  759. — Medication  of  the  renal  pelvis. 

Instruments. — In  addition  to  the  apparatus  necessary  for  ureteral 
catheterization  (see  pages  705.  715)  there  will  be  required  a  glass 
syringe  with  a  capacity  of  2  1/2  drams  (10  c.c.)  supplied  with  a  blunt 
nozzle  sufficiently  small  to  fit  into  the  end  of  the  catheter. 

Asepsis. — The  same  precautions  against  infection  should  be 
observed  as  detailed  under  ureteral  catheterization  (pages  707,  716). 

Solutions  Used.— Sterile  water,  a  saturated  solution  of  boric  acid, 
silver  nitrate  in  the  strength  of  i  to  8000  increased  in  strength  up  to 
I  to  2000.  protargol  i  to  500  to  2  per  cent.,  argyrol  2  to  5  per  cent., 
collargol4  per  cent.,  bichlorid  of  mercury  i  to  150,000  to  i  to  16,000 
may  be  employed.     Too  strong  solutions  will  result  in  colic. 

For  the  purpose  of  aiding  the  passage  of  an  impacted  calculus 
injections  of  sterile  olive  oil  have  been  employed. 


THE    DILATATION    OF    URETERAL    STRICTURES  733 

Temperature. — The  solution  should  be  at  a  temperature  of  100"^ 
F.  (38°  C). 

Quantity. — One  to  2  drams  (about  5  to  10  c.c.)  of  solution  are 
generally  injected  at  a  time.  If  large  amounts  are  employed,  over- 
distention  of  the  renal  pelvis  will  result  with  consequent  colic. 

Frequency. — The  treatments  may  be  applied  once  or  twice  a 
week. 

Position  of  Patient.— Same  as  for  ureteral  catheterization  (pages 
707,  716). 

Anesthesia. — (Seepages  707,  717.) 

Preparations  of  Patient. — The  same  as  for  ureteral  catheteriza- 
tion (pages  708,  717^. 

Technic. — The  catheter  is  inserted  into  the  renal  pelvis  as  pre- 
viously described  (pages  708,  717).  Any  fluid  or  pus  collection  is 
then  allowed  to  drain  off,  and  the  tip  of  the  syringe,  charged  with  the 
solution,  is  introduced  into  the  end  of  the  catheter  and  i  or  2  drams 
(about  5  to  10  c.c.)  of  solution  are  injected.  Care  must  be  taken  to 
see  that  the  syringe  contains  no  air  and  the  injection  must  be  given 
very  slowly  and  evenly  to  avoid  a  sudden  distention  of  the  kidney  pel- 
vis. The  syringe  is  then  disconnected,  the  patient  is  raised  to  a 
semiupright  position,  and  the  solution  is  aU  aUowed  to  escape;  if  a 
small  catheter  is  employed,  the  solution  may,  however,  escape  beside 
it  into  the  bladder.  This  washing-out  process  may  be  repeated 
until  the  solution  returns  clear.  The  syringe  is  again  connected 
with  the  catheter  which  is  slowly  withdrawn,  the  solution  being 
injected  the  while  so  as  to  medicate  the  entire  ureter.  At  the  com- 
pletion of  the  operation  the  bladder  is  irrigated. 

To  aid  the  passage  of  a  ureteral  calculus  by  the  injection  of  olive 
oil,  the  following  technic  is  employed:  a  ureteral  catheter  is  passed 
beyond  the  stone  if  possible,  and,  if  not,  up  to  it,  and  a  few  drops  of 
sterile  olive  oil  are  injected.  This  acts  as  a  lubricant  and  the  stone 
is  often  readily  passed  as  a  result. 

THE  DILATATION  OF  URETERAL  STRICTURES 

The  gradual  dilatation  of  ureteral  strictures  may  be  performed  by 
suitable  bougies,  introduced  with  the  aid  of  the  cystoscope.  While  it 
is  doubtful  if  a  permanent  cure  can  be  obtained  in  many  cases  by  this 
method,  as  such  strictures,  like  those  of  the  urethra,  rectum,  etc.,  tend 
to  recontract  in  the  majority  of  cases,  the  patient  is  greatly  benefited 
for  the  time  being  through  relief  of  the  distention  of  the  ureter  and 


734 


THE  KIDNEYS  AND  URETERS 


kidney  pelvis  caused  b}-  the  obstruction.  The  majority  of  strictures 
are  located  near  the  ureteral  orifices,  and  these  are  most  readily  di- 
lated, though  the  method  may  be  applied  with  success  to  strictures  in 
any  part  of  the  canal. 

Instruments. — Dilatation  may  be  affected  by  means  of  flexible 
whalebone  bougies,  flexible  catheters  or,  if  the  stricture  is  near  the 
vesical  end,  by  metal  catheters.  These  instruments  as  well  as  the 
cystoscopes  have  been  already  described  (pages  705,  715). 

Asepsis. — (See  pages  707.    716.) 


Fig.  760. — Showing  the  method  of  dilating  a  ureteral  stricture. 
(After  Kelly  and  Noble.) 


Frequency  of  Dilatation. — Treatments  are  employed  every  two  or 
three  days. 

Position  of  Patient. — Same  as  for  ureteral  catheterization  (pages 
707,  716). 

Preparations. — (See  pages  708,   717.) 

Anesthesia. — (See  pages  707,  717.) 

Technic. — The  ureteral  orifice  is  located  as  already  described  and 
the  dilator  is  introduced  into  the  ureter  in  the  same  manner  as  the 
ureteral  catheter  (pages  708,  717).  Choosing  an  instrument  that  the 
stricture  will  readily  admit,  it  is  passed  completely  through  the  stric- 
ture and  is  left  in  place  for  a  few  moments  and  then  a  larger  size  is 
inserted.  At  the  next  treatment  the  stricture  is  dilated  one  or  two 
sizes  more  until  finally  it  is  stretched  sufficiently  to  admit  a  No.  5  or 
6  catheter  with  ease.  Following  each  treatment  lavage  of  the  kidney 
pelvis  and  ureter  may  be  practised  as  described  above. 


CHAPTER  XXII 
THE  FEMALE  GENERATIVE  ORGANS 

Anatomic  Considerations 

The  Vagina.  — The  vagina  is  a  musculo-membranous  canal  ex- 
tending from  the  uterus  to  the  vulva,  lying  bet^Yeen  the  bladder  and 
urethra  in  front  and  the  rectum  behind.  ^Mth  the  woman  in  an  erect 
posture  it  is  directed  downward  and  forward  at  an  angle  of  60  degrees 
with  the  horizon.  The  anterior  wall,  which  is  shorter  than  the  poste- 
rior wall,  due  to  the  position  of  the  cervix,  measures  2  to  2  1/2  inches 
(5  to  6  cm.;  in  length,  while  the  posterior  wall  measures  3  to  3  1/2 
inches  (7.5  to  9  cm.).  Xormally  the  walls  are  in  contact,  but  when 
distended  the  vagina  becomes  conical  in  shape  and  larger  above  than 
below^  That  portion  surrounding  the  cervix  uteri  is  spoken  of  as  the 
roof  or  fornix.  It  is  divided  for  description  into  four  parts:  the  ante- 
rior fornix,  in  which  is  normally  felt  the  body  of  the  uterus;  the  pos- 
terior forniX;  the  deepest  portion,  which  is  in  close  relation  with  the 
cul-de-sac  of  Douglas;  and  the  two  lateral  fornices. 

Relations. — Anteriorly,  in  its  lower  portion  the  vagina  is  in  relation 
with  the  urethra  and  in  its  upper  half  with  the  neck  and  fundus  of  the 
bladder.  Posteriorly,  it  is  in  relation  with  the  perineal  body  in  its 
lower  quarter,  in  its  upper  quarter  with  the  cul-de-sac  of  Douglas, 
and  between  the  two  with  the  rectum. 

Structure. — It  consists  of  a  mucous,  muscular,  and  connective- 
tissue  coat.  The  mucous  membrane,  which  is  of  the  squamous  va- 
riety, exhibits  on  the  anterior  and  posterior  walls  numerous  ridges, 
or  rugse,  which  extend  out  transversely  from  a  central  column.  They 
are  more  distinct  on  the  anterior  wall. 

The  muscular  coat  is  arranged  in  two  layers,  an  inner  longitudinal 
and  an  outer  circular. 

The  connective- tissue  coat  is  a  thin  fibrous  structure  containing  a 
few  smooth  muscle  fibers.  In  its  meshes  this  layer  gives  support  to  a 
plexus  of  veins. 

The  Uterus  and  Appendages. — The  uterus,  or  womb,  is  a  hol- 
low pear-shaped  organ  lying  in  the  pelvis  between  the  bladder  and  the 
rectum.  It  measures  about  3  inches  (7.5  cm.)  in  length,  2  inches 
(5  cm.)  in  breadth,  and  i  inch  (2.5  cm.)  in  thickness. 

735 


736 


THE  FEMALE  GENERATIVE  ORGANS 


Externally,  it  is  flattened  from  before  backward,  and  at  the  point 
where  the  peritoneum  is  reflected  from  the  uterus  to  the  bladder  there 
appears  a  constriction,  the  isthmus,  which  corresponds  with  the  posi- 
tion of  the  internal  os  and  divides  the  uterus  into  two  portions.  The 
portion  lying  below  the  isthmus  is  the  cervix,  that  part  between  the 
isthmus  and  a  line  joining  the  entrance  of  the  tubes  is  known  as  the 
body,  while  the  portion  above  the  plane  of  the  entrance  of  the  tubes  is 
known  as  the  fundus.  The  cervix  in  turn  is  also  divided  into  three 
portions:  an  infravaginal  portion,  below  the  attachment  of  the  ante- 
rior vaginal  wall;  a  supravaginal  portion,  above  the  attachment  of  the 
posterior  vaginal  wall;  and  an  intermediate  portion,  lying  between 
the  two. 


Fig.  761. — The  normal  position  of  the  uterus.     (Ashton.) 

The  interior  of  the  uterus  measures  about  2  1/2  inches  (6  cm.)  in 
length  and  is  divided  into  two  portions  by  the  internal  os.  That 
portion  of  the  canal  above  this  point  is  triangular  in  shape  with  the 
base  upward  and  with  the  walls  normally  in  contact.  In  the  cervical 
portion  the  canal  is  fusiform  in  shape.  Ihe  uterus  opens  into  the 
vagina  through  the  external  os,  a  transverse  aperture  having  an  ante- 
rior and  a  posterior  lip,  while  above  it  connects  with  the  peritoneal 
cavity  through  the  Fallopian  tubes. 

Position  of  Uterus. — Normally  the  uterus  lies  in  a  slightly  ante- 
flexed  position  with  the  fundus  pointing  toward  the  umbilicus  (Fig. 
761).  Its  position,  however,  is  modified  from  time  to  time  by  the 
neighboring  organs.  Thus  a  distended  bladder  will  push  it  toward 
the  sacrum,  while  a  full  rectum  pushes  it  forward. 


DIAGNOSTIC    METHODS 


737 


structure. — The  litems  is  made  up  of  a  mucous,  muscular,  and  a 
peritoneal  coat.  The  mucous  membrane  of  the  body  of  the  uterus  is 
smooth  and  pale  in  color,  with  the  mouths  of  numerous  tubular  glands 
opening  upon  its  surface.  The  lining  epithelium  is  of  the  ciliated 
variety  having  a  motion  from  within  outward. 

In  the  cervix  it  is  firmer  in  structure  and  is  thrown  into  numerous 
folds,  the  arbor  vitse.  These  are  arranged  in  the  form  of  a  median 
ridge  on  the  anterior  and  posterior  walls,  from  which  branch  second- 
ary ridges  in  an  upward  and  outward  direction.  Between  these 
ridges  are  located  the  openings  of  tubular  and  racemose  glands.  In 
the  upper  portion  of  the  cervix  the  mucous  membrane  is  the  same  as 
that  found  in  the  body  of  the  uterus  and  below  it  is  similar  to  that  in 
the  vagina. 

Extending  out  from  either  superior  angle  of  the  uterus  are  the  two 
Fallopian  tubes.  They  measure  3  to  5  inches  (7.5  to  12.5  cm.)  in 
length  and  lie  in  the  free  borders  of  the  broad  Hgaments  between  the 
ovaries  behind  and  the  round  ligaments  in  front.  They  are  lined 
with  ciliated  epithelium  having  a  direction  toward  the  uterus.  Their 
external  apertures,  the  fimbriated  extremities,  open  into  the  perit- 
oneal cavity  near  the  ovary.  Internally,  each  tube  opens  into  the 
uterine  cavity  at  its  superior  angle. 

The  ovaries,  two  in  number,  lie  on  either  side  of  the  uterus,  about 
on  a  level  with  the  pelvic  brim,  near  the  abdominal  extremities  of  the 
tubes.  Each  ovary  measures  i  1/2  inches  (4  cm.)  in  length,  3/4  inch 
(2  cm.)  in  breadth,  and  1/3  to  1/2  inch  (0.8  to  i  cm.)  in  thickness. 

Diagnostic  Methods 

In  making  a  gynecological  examination  the  investigation  should 
comprise  an  inquiry  into  the  patient's  general  condition  as  well  as  an 
examination  of  the  pelvic  organs.  A  clear  and  concise  history  of  the 
subjective  symptoms  should  be  the  first  step  in  every  case.  It  is 
preferable  to  allow  the  patient  to  first  detail  her  own  symptoms  and  to 
supplement  this  by  inquiry  as  to  essential  points.  In  doing  this  it  is 
well  to  follow  a  routine  system  in  order  to  avoid  omitting  some  impor- 
tant point  that  may  have  direct  bearing  upon  the  case,  and  also  that 
the  examiner  may  have  a  complete  record  for  future  reference. 

In  addition  to  the  usual  questions  commonly  asked  in  obtaining  a 
history,  special  information  should  be  sought  in  regard  to  the  follow- 
ing points :  First  the  menstrual  history  should  be  inquired  into,  ascer- 
taining the  age  at  which  menstruation  began,  the  precautions  taken 
during  menstruation,  the  interval  between  the  periods,  the  regularity 
47 


738  THE  FEMALE  GENERATIVE  ORGANS 

of  the  periods,  the  duration  of  the  flow,  and  its  character,  whether 
painful,  whether  accompanied  by  the  passage  of  clots,  and  whether 
scanty  or  profuse.  The  latter  is  especially  important,  as  excessive 
menstrual  bleeding  points  to  the  presence  of  some  pathological 
condition. 

With  a  history  of  painful  menstruation  the  time  the  pain  begins 
and  ceases  in  relation  to  menstruation  should  be  ascertained.  It 
should  also  be  found  out  whether  there  has  been  any  bleeding  between 
the  periods.  If  the  menopause  has  occurred,  its  date  and  the  presence 
or  absence  of  any  bleeding  since  are  to  be  noted.  If  the  patient  is 
married,  certain  data  relating  to  child-bearing  should  be  sought,  com- 
prising the  number  of  children,  the  dates  of  their  births,  a  history  of 
the  labors,  whether  easy,  difficult,  or  instrumental,  and  whether  they 
were  followed  by  a  long  and  protracted  convalescence. 

With  a  history  of  abortions  or  miscarriages  the  period  of  preg- 
nancy at  which  they  occurred  and  their  probable  cause  should  be 
ascertained.  At  times  it  is  also  important  to  know  something  of  the 
marital  relations,  that  is,  the  frequency  of  coitus,  whether  the  act  is 
painful  and  whether  measures  to  prevent  conception  have  been  em- 
ployed, and,  if  so,  the  methods  used. 

The  patient  is  next  questioned  as  to  the  presence  or  absence  of  a 
vaginal  discharge.  If  present,  its  character  should  be  inquired  into, 
whether  foul,  blood-tinged,  or  having  the  characteristics  of  an  ordi- 
nary leucorrhea.  The  quantity  of  discharge  is  also  to  be  noted,  and 
whether  it  is  always  present  or  only  occurs  midway  between  the 
monthly  periods. 

Pain  is  another  frequent  and  important  complaint  upon  which  full 
information  should  be  sought.  The  character  and  situation  of  the 
pain  should  always  be  determined.  The  pain  complained  of  may  be 
in  the  form  of  a  headache,  a  bearing-down  feeling,  backache,  or  its 
situation  may  be  referred  to  some  part  of  the  pelvis,  the  coccyx,  or  the 
inguinal  region.  Inguinal  pain  generally  points  to  some  disease  of 
the  uterine  appendages  or  ligaments;  on  the  other  hand,  backache  is 
found  as  an  accompaniment  of  a  number  of  conditions,  such  as  chronic 
constipation,  uterine  displacements,  pelvic  tumors,  etc.,  while  pain 
in  the  coccyx  is  often  a  symptom  of  neurasthenia.  It  should  also  be 
ascertained  if  the  pain  is  modified  by  menstruation,  and  if  so,  whether 
it  is  worse  before  the  flow  begins,  during  the  flow,  or  afterward,  also 
whether  it  is  affected  by  exercise,  any  sudden  jolt  or  jar,  or  by  coitus. 

Finally,  since  many  gynecological  patients  have  in  addition  to 
their  pelvic  troubles  other  disorders,  the  general  symptoms  and  the 


PREPAEAT.ON    OF    PATIENT    FOE.    EXAMINATION  739 

functions  o^  other  organs  should  be  similarly  inquired  into.  Thus 
the  patient  should  be  questioned  as  to  her  appetite,  loss  of  weight, 
nausea  and  vomiting,  and  if  the  latter  is  present,  its  character  and 
relation  to  the  taking  of  food,  the  condition  of  the  bowels,  and  whether 
she  sleeps  well  or  suffers  from  nervousness,  hysteria,  palpitation  of  the 
heart,  hot  flashes,  etc.,  etc. 

Having  obtained  the  above  data,  a  thorough  physical  examina- 
tion is  then  made.  It  should  comprise  a  careful  observation  of  the 
patient's  general  condition,  color,  and  nutrition,  and  an  examination 
of  the  heart,  lungs,  nervous  system,  urine,  and  blood.  After  this  is 
completed  the  patient  is  prepared  for  a  general  examination  of  the 
abdomen  and  pelvic  organs. 

The  methods  available  for  such  examination  include  abdominal 
inspection,  palpation,  percussion,  auscultation,  and  mensuration, 
internal  examination  by  inspection  and  palpation,  the  use  of  specula 
and  the  uterine  sound,  digital  exploration  of  the  uterus,  test  excision, 
test  curettage,  and  exploratory  incision. 

Preparation  of  Patient. — Certain  preparation  of  the  patient  is 
essential  for  a  thorough  examination,  otherwise  the  results  will  be 
unsatisfactory.  If  an  anesthetic  is  to  be  given,  the  preparations  for 
such,  previously  detailed  (page  2),  should  be  carried  out.  In  any 
case,  the  bowels  should  be  thoroughly  evacuated  by  means  of  a  mild 
purgative  taken  the  day  before,  followed  by  an  enema  on  the  morning 
of  the  examination.  The  bladder  is  emptied  spontaneously  just 
before  the  patient  presents  herself  for  examination. 

A  suitable  examining- table  should  be  provided,  and  the  simpler 
it  is  the  better.  It  should  be  about  3  feet  (90  cm.)  high,  strong  in 
construction,  provided  with  adjustable  foot-rests,  and  capable  of 
being  lengthened  so  that  the  patient  may  be  placed  upon  it  in  the 
horizontal  position.  A  small  step,  to  aid  the  patient  in  mounting, 
is  also  necessary.  A  second  small  table  should  be  placed  near  at 
hand,  upon  which  are  placed  solutions,  instruments,  etc.,  that  may  be 
required  during  the  examination. 

When  it  is  necessary  to  make  a  vaginal  examination  in  the 
patient's  home,  an  ordinary  kitchen  table  or  the  bed  may  be  utilized. 
In  the  latter  case  the  patient  is  placed  lengthwise  across  the  bed,  with 
an  ironing-board  covered  by  several  thicknesses  of  a  sheet  placed  on 
the  mattress  under  the  patient's  hips,  and  with  the  patient's  feet 
supported  on  two  chairs  (Fig.  717). 

With  the  patient  in  the  desired  position  upon  the  table  it  should 
be  seen  that  the  corsets  and  any  constricting  bands  are  removed  from 


740 


THE  FEMALE  GENERATIVE  ORGANS 


about  the  waist  and  that  the  patient  is  so  covered  by  sheets  that  only 
the  region  to  be  examined  is  exposed.  For  an  abdominal  examina- 
tion two  sheets  are  employed,  one  draped  over  the  pelvic  region  and 
lower  part  of  the  abdomen  and  the  other  over  the  upper  abdomen. 
For  a  vaginal  examination  the  sheet  is  thrown  over  the  lower  extrem- 
ities and  is  then  separated  so  as  to  expose  the  vulva.  If  the  examiner 
is  provided  with  a  nurse,  these  details  may  be  left  to  her.  While  a 
nurse  is  not  absolutely  necessary,  it  is  always  preferable  to  have  some 
woman  present  at  the  examination,  not  only  for  the  greater  comfort 
of  the  patient,  but  for  the  protection  of  the  physician  against  malici- 
ous charges  at  the  hands  of  unscrupulous  females. 


Fig.    762. — Position  of  the  patient  for  an  examination  upon  a  bed.      (Ashton.) 

Gynecological  Postures. — In  examining  the  female  pelvic  organs 
a  number  of  postures  are  available.  These  include  the  dorsal,  the 
Sims,  the  knee-chest,  the  erect,  and  the  squatting  positions. 

The  dorsal  position,  which  is  the  best  for  digital  or  bimanual 
examinations,  is  obtained  by  placing  the  patient,  facing  the  light,  flat 
on  the  back,  with  the  hips  near  the  edge  of  the  table  and  with  the 
feet  supported  upon  the  foot-rests  (Fig.  762). 

The  Sims  position  is  obtained  by  placing  the  patient  upon  her 
left  side,  with  the  left  side  of  the  face,  the  left  shoulder,  and  left 
breast  resting  upon  a  flat  pillow.  The  left  arm  lies  behind  the  back, 
the  thighs  are  well  flexed  upon  the  body,  and  the  right  knee  is  drawn 


GYNECOLOGICAL    POSTURES 


741 


up  nearer  the  body  than  the  left  ('see  Fig.  538).  In  this  position  an 
excellent  xiev:  may  be  obtained  of  the  vaginal  fornices,  the  anterior 
vaginal  wall,  and  the  cervix,  but  it  is  not  satisfactory  for  a  digital 


Fig.  763. — The  patient  in  the  dorsal  position.      (Ashton.) 


Fig.   764. — Examination  with  the  patient  standing  erect.      (Ashton.) 

examination,  as  the  pelvic  organs  are  more  diiScult  to  reach  than 
w-ith  the  patient  in  the  dorsal  posture. 

The  knee-chest  position  is  obtained  b}-  having  the  patient  kneel 

upon  a  table,  with  the  thighs  at  right  angles  to  the  legs,  the  chest 


742  THE  FEMALE  GENERATRE  ORGANS 

resting  upon  a  pillow  placed  upon  the  same  level  as  the  knees  (see 
Fig.  540).  In  this  posture  the  intestines  gravitate  toward  the  dia- 
phragm, and  the  vagina  becomes  distended  so  that  the  numerous  folds 
of  mucous  membrane  are  spread  out  smoothly. 

The  Erect  Posture. — The  patient,  with  her  clothes  elevated  and  a 
sheet  fastened  about  her  hips,  stands  with  one  foot  on  the  floor  and 
the  other  resting  upon  a  stool  6  to  8  inches  (15  to  20  cm.)  high.  The 
examiner  kneels  in  front  of  the  patient  and,  passing  his  hand  beneath 
the  sheet,  makes  a  digital  examination  of  the  vaginal  outlet  and  the 
uterus  (Fig.  764) .  In  this  position  a  prolapse  of  the  uterus  or  a  relaxa- 
tion of  the  vaginal  outlet  is  more  readily  recognized  than  in  the 
dorsal  posture. 

The  squatting  posture  is  sometimes  useful  in  ascertaining  the  degree 
of  a  uterine  prolapse  and  the  relaxation  of  the  vaginal  walls.  The 
patient  takes  the  same  position  as  when  at  stool  and,  by  a  slight 
straining  effort,  any  tendency  to  prolapse  is  readily  made  visible  to 
the  examiner. 

Asepsis. — In  all  gynecological  examinations  every  precaution 
must  be  taken  to  avoid  infecting  a  patient  as  well  as  to  prevent  infec- 
tion of  the  examiner  by  the  patient.  All  instruments  that  are  used 
are  boiled  for  live  minutes  in  a  i  per  cent,  soda  solution,  and  no  instru- 
ment should  be  used  on  more  than  one  patient  without  resterilization. 
The  examiner's  hands  are  sterilized  by  a  thorough  scrubbing  with 
tincture  of  green  soap  and  water,  followed  by  immersion  in  an  anti- 
septic solution.  The  examiner  should  also  see  that  his  finger-nails 
are  cut  short  to  avoid  hurting  the  patient. 

If  the  patient  is  suspected  of  having  syphilis  or  gonorrhea,  or  in 
the  presence  of  a  septic  discharge,  the  examiner  should  protect  him- 
self by  wearing  rubber  gloves  previously  sterilized  by  boiling.  In 
the  majority  of  cases  it  is  sufficient  to  wipe  off  the  vulva  with  a  swab 
soaked  in  a  i  to  2000  bichlorid  solution,  but  where  a  profuse  or  foul 
discharge  is  present  a  vaginal  douche  should  be  given.  When  it  is 
desired  to  obtain  a  specimen  of  a  discharge  for  examination,  antisep- 
tic solutions  or  douches  should  be  omitted  until  this  has  been  done. 

/.  Examination  of  the  Abdomen 

INSPECTION 

From  the  appearance  of  the  skin,  the  shape  of  the  abdomen,  and 
the  effect  of  respiration  upon  a  tumor  valuable  information  may  be 
obtained. 


PALPATION 


743 


Position  of  Patient. — The  patient  should  lie  with  the  body  sym- 
metrically placed  upon  a  firm  flat  table  in  the  horizontal  position, 

Technic. — With  the  patient's  abdomen  entirely  exposed  and  the 
light  falling  obliquely  upon  the  abdomen,  the  examiner  inspects  it 
first  from  the  side  and  then  from  the  foot  of  the  table  (see  Fig.  491). 
The  color  of  the  skin  of  the  abdomen,  the  presence  or  absence  of 
striae,  eruptions,  scars,  edema,  and  dilated  veins,  the  condition  of  the 
abdominal  walls,  whether  rigid  or  lax,  and  the  shape  and  symmetry 
of  the  abdomen  should  all  be  noted. 

In  enlargement  of  the  abdomen  due  to  obesity,  the  lower  portion 
of  the  abdominal  wall  usually  hangs  down  over  the  patient's  thighs. 
In  ascites  the  abdomen  is  more  or  less  flattened,  and  the  sides 
bulge  outward.  In  the  presence  of  pregnancy  or  an  ovarian  cyst  the 
enlargement  is  smooth  and  regular,  in  the  former  case  the  abdo- 
men being  symmetrically  enlarged,  while  an  ovarian  cyst,  especially 
if  small,  may  distend  one  side  only.  Fibroid  tumors  may  present  as 
irregular  and  nodular  growths.  If  a  tumor  is  discovered,  the  pres- 
ence or  absence  of  mobility  with  respiration  and  whether  the  ab- 
dominal walls  move  over  the  growth  should  be  noted.  Evidence  of  a 
weakened  condition  of  the  recti  muscles  or  the  presence  of  a  hernia 
should  also  be  sought  by  having  the  patient  strain  and  cough. 

PALPATION 

Palpation  of  the  abdomen  is  the  most  satisfactory  of  the  methods 
of  abdominal  examination  and  should  form  a  part  of  every  routine 
gynecological  examination.  By  it  the  presence  of  tumors,  rigidity, 
fluctuation,  or  local  tenderness  that  might  escape  notice  by  trusting 
simply  to  a  vaginal  examination  may  be  recognized,  and,  in  the  pres- 
ence of  an  enlargement,  its  situation,  origin,  shape,  mobility,  and 
consistency  may  be  determined. 

Position  of  Patient. — The  patient  lies  in  the  dorsal  position,  with 
the  shoulders  slightly  elevated  and  the  thighs  somewhat  flexed  to 
secure  thorough  relaxation. 

Technic. — The  examiner  first  thoroughly  warms  his  hands. 
Then,  taking  his  place  upon  one  side  of  the  patient,  he  systematic- 
ally palpates  all  portions  of  the  abdomen.  In  doing  this  the  pal- 
pating hand — usually  the  right — is  placed  upon  the  abdomen,  palm 
downward,  and  firm  but  gentle  pressure  is  made — sharp  pressure 
with  the  finger  tips  should  be  avoided  as  it  incites  the  muscles  to 
contract.  Local  or  general  rigidity  of  the  abdominal  wall,  sensi- 
tive areas,  and  the  presence  of  a  tumor  are  thus  ascertained. 


744 


THE  FEMALE  GENERATIVE  ORGANS 


To  differentiate  obesity  from  intraabdominal  growths  both  hands 
are  employed  and  make  deep  pressure  from  the  sides  toward  the 
mid-line,  at  the  same  time  lifting  upward  on  the  abdominal  walls 


Fig.  765. — Showing  the  method   of  estimating  the  thickness  of  the 
abdominal  walls. 

(Fig.  765).  The  situation,  origin,  size,  or  mobility  of  a  tumor  is 
determined  by  making  deep  pressure  with  both  hands  in  all  direc- 
tiDns  about  the  mass  (Fig.  766).  An  enlarged  uterus  is  mapped  out 
in  the  same  manner.     In  examining  the  lateral  regions  of  the  abdo- 


FiG.  766. — Bimanual  palpation  of  an  abdominal  tumor.      (Ashton.) 

men  bimanual  palpation  is  often  of  service,  one  hand  being  placed 
under  the  flank  and  making  forward  pressure  while  the  other  hand 
palpates  the  antero-lateral  surface  of  the  abdomen. 


PERCUSSION 


745 


Fluid  collections  are  recognized  by  a  thrill  or  wave  produced  by 
placing  one  hand  with  the  palm  flat  on  one  side  of  the  abdomen  and 
tapping  the  abdomen  from  the  opposite  side  with  the  fingers  of  the 
other  hand.  To  avoid  confusing  a  wave  produced  by  tapping  a  fat 
abdomen  with  that  of  fluid  the  examiner  should  have  an  assistant 
place  the  ulnar  edge  of  his  hand  firmly  on  the  summit  of  the  abdo- 
men while  the  tapping  is  performed  (Fig.  767).  In  the  case  of  fat 
the  wave  is  then  absent. 


Fig.  767. — Method  of  differentiating  between  a  wave  produced  when  tapping 
fat  abdomen  and  one  containing  fluid.      (Ashton.) 


PERCUSSION 

Abdominal  percussion  is  valuable  when  employed  as  an  adjunct 
to  inspection  and  palpation  in  differentiating  between  tympany, 
ascites,  cystic  and  sofid  tumors,  and  in  determining  the  size  and 
shape  of  a  tumor,  and  its  origin.  To  avoid  errors,  the  large  intes- 
tine should  be  emptied  by  an  enema  before  the  examination. 

Position  of  Patient. — Percussion  is  performed,  first,  with  the 
patient  lying  on  the  back  and,  then,  turned  upon  the  side. 

Technic. — The  examiner  places  the  palmar  surface  of  the  middle 
finger  of  the  left  hand  firmly  upon  the  area  to  be  percussed  and, 
using  the  tip  of  the  middle  finger  of  the  right  hand,  bent  at  a  right 
angle,  as  a  plexor,  strikes  quick,  sharp  blows  (see  Fig.  497)-  The 
normal  resonance  of  the  abdomen  is  tympanitic  except  in  the  regions 
of  the  liver  and  spleen  where  it  is  dull.  Fecal  masses,  cystic  and  solid 
tumors,   and  fluid  collections  give  dulness  on  percussion.     When 


746 


THE  FEMALE  GEXERATR'E  ORGANS 


distended  intestines  overlie  a  growth,  however,  the  note  will  be  tym- 
panitic, and  it  will  be  necessary  to  employ  deep  and  strong  percus- 
sion to  bring  out  the  dulness.     By  carefully  percussing  around  the 


^tympanv^ 


Fig.  768. — Showing  the  area  of  dulness  and  tympany  in  ascites  when  the  patient  is 

recumbent.     (Ashton.) 

margins  of  a  tumor  and  noting  where  tympanitic  resonance  is  absent, 
it  is  often  possible  to  determine  the  origin  of  the  growth. 

In  the  presence  of  ascites  with  the  patient  in  the  dorsal  position, 
dulness  will  be  elicited  in  the  flanks,  while  the  center  of  the  abdomen 


^^UPANV^ 


Fig.  769. — Showing  the  area  of  dulness  and  tympany  in  ascites  when  the  patient 
lies  on  her  side.      (Ashton.) 


will  be  tympanitic,  as  the  intestines  float  to  the  highest  point  (Fig. 
768).  With  a  change  in  the  patient's  position  the  fluid  gravitates  to 
the  lowest  point  and  the  location  of  the  dulness  and  tympany  is  like- 
wise changed  (Fig.  769).  On  the  other  hand,  the  area  of  dulness  due 
to  tumors  is  not  aft'ected  by  changes  in  the  patient's  position. 


MENSURATION 


747 


AUSCULTATION 

Auscultation  is  of  limited  use  except  in  the  differential  diagnosis 
between  pregnancy  and  other  tumors.  In  the  former  case  the  fetal 
heart  sounds  and  the  funic  souffle  settle  the  diagnosis.  Much  impor- 
tance cannot  be  attached  to  the  uterine  bruit,  however,  in  the  ab- 
sence of  other  signs  pointing  to  pregnancy,  as  it  is  also  heard  in  large 
fibroid  tumors.  In  some  cases  of  peritonitis  it  may  be  possible  to 
hear  a  friction  note. 

MENSURATION 

Mensuration  of  the  abdomen  is  useful  in  determining  whether  the 
abdomen  is  symmetrically  enlarged  or  not,  in  noting  an}-  increase  of 
ascites,  and  in  recording  the  rapidity  of  enlargement  in  a  tumor. 

Position  of  Patient. — The  measurements  are  taken  with  the 
patient  in  the  horizontal  recumbent  position. 


Fig.  770. — Showing  the  measurements  taken  in  recording  the  growth  of  an 

abdominal  tumor. 

Technic. — An  ordinary  tape  measure  is  employed  and  the  follow- 
ing measurements  are  taken:  (i)  the  circumference  of  the  abdomen 
at  the  level  of  the  umbilicus,  (2)  the  distance  from  the  ensiform  carti- 
lage to  the  pubes,  (3)  the  distance  from  the  umbilicus  to  each  anterior 
superior  spine,  (4)  the  distance  between  the  two  anterior  superior 
spines,  and  (5)  the  distance  from  the  anterior  superior  spines  to  the 
pubes  (Fig.  770).  To  have  any  value  for  purposes  of  comparison, 
these  measurements  should  be  taken  from  the  same  points  each 
time  and  with  the  patient  in  exactly  the  same  position. 


748  THE    FEMALE    GENERATIVE    ORGANS 

//.  Examination  of  the  Pelvic  Organs 

INSPECTION 

A  careful  inspection  of  the  external  genitals  and  the  vaginal 
orifice  should  always  be  made  as  a  routine  before  a  digital  examina- 
tion, otherwise  lesions  involving  the  vulva  and  neighboring  parts 
may  escape  notice.  Inflammations,  new  growths,  the  presence  of 
abnormal  secretions,  prolapse  of  the  anterior  or  posterior  vaginal 
walls,  lacerations  of  the  perineum,  and  many  other  pathological  con- 
ditions are  readily  recognized  by  inspection. 


Fig.  771. — Inspection  of  the  vaginal  outlet.      (Bandler.) 

Position  of  the  Patient. — Inspection  is  performed  with  the  pa- 
tient in  the  dorsal  posture  with  the  feet  toward  the  light. 

Technic. — The  examiner  sits  or  stands  facing  the  vulva  and  be- 
gins his  inspection  without  disturbing  the  relation  of  the  parts.  He 
should  first  note  the  general  appearance  of  the  vulva,  whether  the 
labia  are  closed  or  in  apposition,  and  whether  the  vulva  is  the  seat  of 


INSPECTION 


749 


inflammation,  ulcerations,  warts,  swelling,  edema,  varicosites,  erup- 
tions, or  excoriations,  the  latter  a  frequent  accompaniment  of  a  dis- 
charge. If  a  discharge  is  present,  its  color,  quantity,  and  other 
characteristics  should  be  noted. 

The  labia  are  next  separated  with  the  fingers  of  the  left  hand,  and 
the  entrance  to  the  vagina  is  inspected  (Fig.  771),  noticing  the  color 
of  the  mucous  membrane,  the  presence  or  absence  of  the  hymen,  the 
condition  of  the  openings  of  the  ducts  of  Bartholin  and  the  orifice  of 
the  urethra,  and  the  presence  or  absence  of  lacerations,  cystocele, 
or  rectocele.  By  instructing  the  patient  to  bear  down  or  strain 
slightly,  a  prolapse  of  the  anterior  or  posterior  vaginal  walls  is  made 


Fig.  772. — Method  of  exposing  the  anterior  and  posterior  vaginal  walls  for 
inspection.     (Ashton.) 

more  evident.  The  hood  of  the  clitoris  should  also  be  retracted  and 
an  examination  made  for  adhesions  or  concretions  that  may  be  the 
cause  of  nervous  symptoms.  By  retracting  the  perineum  with  two 
fingers  inserted  in  the  vagina,  as  shown  in  Fig.  772,  the  lower  portion 
of  the  anterior  and  posterior  vaginal  walls  may  be  brought  to  view. 

EXAMINATION  OF  DISCHARGES 


If  an  abnormal  discharge  is  present,  specimens  should  be  obtained 
at  this  time  for  later  microscopical  or  bacteriological  examination. 
The  importance  of  such  an  examination  cannot  be  too  strongly 
emphasized.  The  technic  for  collecting  and  preparing  the  speci- 
mens has  been  previously  detailed  at  length  in  Chapter  X. 


;:> 


^o 


THE  FEMALE  GENERATR^E  ORGANS 

DIGITAL  PALPATION 


Palpation  by  means  of  the  linger  is  employed  to  obtain  more 
complete  information  as  to  abnormal  conditions  of  the  vulva  or 
vaginal  outlet  discovered  on  inspection,  and  to  determine  the  condi- 
tion of  the  vagina,  vaginal  fornices,  and  the  cervix.  For  a  satis- 
factory examination  of  the  other  pelvic  organs,  bimanual  palpation 
is  necessary. 

Asepsis. — All  the  aseptic  precautions  previously  detailed  (page 
742)  should  be  observed. 


Fig.   773. — The  diagnosis  of  a  cystocele  by  the  aid  of  a  bladder  sound.      (Ashton.) 

Position  of  Patient. — The  dorsal  position  is  ordinarily  employed, 
but  the  erect  posture  will  be  found  useful  in  estimating  the  degree 
of  a  uterine  prolapse. 

Preparations. —  (See  page  739.) 

Technic. — The  examiner  first  palpates  between  the  thumb  and 
forefinger  of  the  right  hand  any  abnormal  conditions,  such  as  swell- 
ings, new  growths,  etc.,  about  the  vulva  and  the  vaginal  outlet,  and 
also  the  glands  of  Bartholin  for  signs  of  inflammation  or  thickening. 

The  labia  are  then  separated  between  the  thumb  and  index- 
finger  of  the  right  hand,  and  the  index-finger  of  the  left  hand,  well 
lubricated,  is  introduced  into  the  vagina.  The  condition  of  the 
vagina  is  then  investigated,  noting  the  presence  or  absence  of 
congenital  malformations,  its  sensitiveness,  its  temperature,  and 
whether  the  vaginal  walls  have  their  normal  roughness  or  are  smooth 


DIGITAL   PALPATION 


751 


and  unduly  relaxed.     By  turning  the  examining  finger  palmar  sur- 
face up  the  anterior  vaginal  wall  may  be  palpated  and  the  presence 


Fig.  774. — Method  of  estimating  the  thickness  of  the  perineum.      (Ashton.) 


Fig.  775. — Digital  palpation  of  the  cervix.     (Ashton.) 

or  absence  of  an  urethrocele  or  a  cystocele  may  be  ascertained.  By 
introducing  a  sound  into  the  bladder  and  palp.ating  its  point  with  the 
finger  in  the  vagina  (Fig.  773)  a  cystocele,  if  present,  may  be  more 


752  THE  FEMALE  GENERATR'E  ORGANS 

readily  recognized.  The  posterior  vaginal  wall  is  likewise  examined 
by  rotating  the  examining  finger,  palmar  surface  back,  and.  by 
placing  the  thumb  of  the  same  hand  near  the  rectum  the  perineum 
may  be  grasped  between  the  two  fingers  and  its  firmness  and  thick- 
ness estimated  (Fig.  774).  The  vaginal  fornices  on  all  sides  of  the 
cervix  are  next  palpated,  noting  their  depth,  any  rigidity,  indura- 
tion, or  tenderness. 

If  the  uterus  is  in  a  normal  position,  it  will  be  possible  to  feel  its 
body  through  the  anterior  fornix,  while,  if  retroverted,  the  latter  will 
be  felt  in  the  posterior  fornix.  The  condition  of  the  uterus  is  more 
satisfactorily  made  out,  however,  by  bimanual  palpation. 

Finally,  the  cervix  is  palpated  (Fig.  775),  noting  especially  its 
size,  whether  closed  or  open,  whether  hard  or  soft,  its  mobility,  and  its 
position,  that  is.  whether  pointing  backward  toward  the  sacrum,  as  in 
retroflexion  of  the  uterus,  or  pointing  forward  toward  the  symphysis, 
as  is  found  when  the  uterus  is  retroverted  or  anteflexed.  The  pres- 
ence or  absence  of  lacerations,  erosions,  cysts,  etc.,  should  also  be 
determined. 

BIMANUAL  PALPATION 

Bimanual  palpation  by  means  of  the  fingers  of  one  hand  in  the 
vagina  or  rectum  and  the  fingers  of  the  other  hand  making  counter- 
pressure  above  the  symphysis  is  the  most  valuable  method  for  in- 
vestigating the  condition  of  the  pelvic  organs.  By  it  one  may  map 
out  the  size  and  shape  of  the  uterus  and  determine  its  consistency, 
position,  mobility,  and  the  presence  or  absence  of  new  growths.  The 
tubes,  ovaries,  broad  ligaments,  etc.,  may  likewise  be  palpated  and 
their  condition  ascertained. 

Vagino-abdominal  palpation  is  the  most  satisfactory  and  the 
more  generally  employed  method.  It  should  be  supplemented  by 
recto-abdominal  palpation,  however,  in  any  doubtful  cases.  The 
latter  method  is  especially  useful  in  exploring  the  posterior  surface 
of  the  uterus  and  the  appendages  in  cases  of  posterior  displacement  of 
the  uterus,  as  these  structures  may  then  be  more  readily  reached 
from  the  rectum  than  from  the  vagina.  Recto-abdominal  palpa- 
tion is  also  indicated  in  children,  in  the  unmarried,  and  in  cases 
where  the  vagina  is  unduly  sensitive  or  obstructed  by  tumors  or  an 
imperforate  hymen. 

To  perform  a  successful  bimanual  examination  it  is  necessary 
that  the  abdominal  walls  be  thin,  relaxed,  and  free  from  tenderness 
upon  pressure,  and  that  the  vagina  be  sufficiently  large  to  admit 


BIMANUAL   PALPATION  753 

the  fingers  of  the  examining  hand.  In  the  case  of  individuals  with 
very  muscular,  fat,  or  rigid  abdominal  walls  or  a  small  vagina  the 
examination  is  usually  unsatisfactory  without  an  anesthetic.  In 
any  case,  the  examination  must  be  performed  with  the  utmost 
gentleness.  Rough  manipulations  accomplish  nothing  and  are  cap- 
able of  causing  great  harm,  especially  in  cases  where  the  pelvis 
contains  a  tube  filled  with  pus,  a  thin-walled  cyst,  an  ectopic  preg- 
nancy, etc. 

Asepsis. — For  the  necessary  precautions  against  infection  see 
page  742. 

Position  of  Patient. — Bimanual  palpation  is  most  satisfactorily 
performed  with  the  patient  in  the  dorsal  position. 

Preparations. — (See  page  739.) 

Anesthesia. — General  anesthesia  is  not  often  required  in  indi- 
viduals with  thin  and  relaxed  abdominal  walls,  but  in  muscular,  fat, 
or  nervous  individuals  or  where  the  parts  are  tender  and  sensitive 
an  anesthetic  may  be  necessary  to  secure  relaxation.  A  general 
anesthetic  should  also  be  employed  if  any  doubt  remains  as  to  the 
conditions  found  after  an  ordinary  bimanual  examination,  and  in 
all  cases  where  it  is  necessary  to  make  a  vaginal  examination  upon 
virgins. 

Technic. — i.  Vagino-ahdominal. — The  examiner  stands  facing 
the  patient  a  little  to  one  side  or  the  other  depending  upon  which 
hand  he  palpates  with.  The  labia  are  then  separated  between  the 
thumb  and  forefinger  of  one  hand  and  the  index-finger  of  the  other 
hand,  or  the  index-  and  middle  fingers  if  the  parts  are  sufficiently 
relaxed  to  admit  them,  are  well  lubricated  and  are  inserted  into  the 
vagina,  while  the  fingers  of  the  free  hand  are  placed  on  the  abdomen 
above  the  pubes.  The  external  hand  is  used  to  steady  or  depress  the 
organs  while  the  internal  hand  does  the  palpating.  As  a  rule  the 
left  hand  is  employed  to  palpate  with,  being  the  smaller  of  the  two  and 
possessing  greater  tactile  sensibility,  but  the  examiner  should  be 
equally  proficient  with  either  hand.  The  last  two  fingers  of  the  in- 
ternal hand  should  be  folded  back  upon  the  palm,  as  shown  in  Fig. 
776,  so  as  to  invaginate  the  pelvic  floor  and  thereby  permit  the 
greatest  possible  penetration.  The  palmar  surfaces  of  the  fingers  of 
the  internal  hand  are  brought  in  contact  with  the  cervix  and  its  con- 
dition and  position  are  first  determined.  With  the  internal  fingers 
in  contact  with  the  cervix  and  exerting  upward  pressure  the  external 
hand  locates  the  fundus  of  the  uterus  and  makes  gentle  pressure  from 
above.     The  length,  sensitiveness,  consistency,  and  position  of  the 


754 


THE  FEMALE  GENERATIVE  ORGANS 


Uterus  are  thus  determined,  and  likewise  the  mobihty  by  making  a 
series  of  gentle  pushes  from  above  and  below  (Fig.  777). 

By  placing  the  internal  lingers  in  front  of  the  cervix  and  the  fingers 


Pig.  776. — Method    of  inserting  the   examining   fingers  in   bimanual   palpation 
Small  figure  shows  the  method  of  holding  the  fingers. 


Fig.  777. — Method    of    determining       Fig.  778. — Method    of   estimating    the 
the  length  and  mobility  of  the  uterus.  thickness  of  the  uterus.      (Ashton.) 

(Ashton.) 

of  the  externa)  hand  behind  the  fundus  the  thickness  of  the  uterus 
may  be  estimated  (Fig.  778).  If  the  fundus  is  pressed  well  forward 
by  the  external  hand,  the  anterior  and  lateral  surfaces  may  be  pal- 
pated and  any  irregularity  of  the  surfaces  which  might  be  caused  by 


BIMANUAL   PALPATION 


755 


fibroids  or  other  growths  is  noted.  By  carrying  the  fingers  of  the 
internal  hand  posterior  to  the  cervix  and  pressing  the  fundus  back- 
ward the  posterior  surface  is  in  hke  manner  explored.     When  the 


Fig.  779. — Diagnosis  of  an  anteflexion   of  the  uterus  by  bimanual  palpation. 

(Ashton.) 


Fig.  780. — Diagnosis  of  a  posterio'r  Fig.  781.— Shows    the    method    of 

displacement  of  the  uterus  by  bimanual      palpating  the  body  of  the  uterus  in  a 
palpation.      (Ashton.)  posterior  displacement.      (Ashton.) 


fundus  is  not  found  in  its  normal  position,  it  should  be  sought  for 
anteriorly  near  the  symphysis,  or  posteriorly.  To  palpate  for  anterior 
displacements,  the  internal  finger  is  carried  up  in  front  of  the  cervix 


756 


THE  FEMALE  GEXERATR'E  ORGANS 


into  the  anterior  fornix  while  the  external  hand  exerts  pressure  down- 
ward behind  the  symphysis.  If  antetiexed,  the  fundus  will  be  readily 
felt  between  the  fingers  of  the  external  and  internal  hands  (Fig. 
779),  while  in  posterior  displacements  the  opposed  fingers  may  be 
brought  together  as  shown  in  Fig.  780.  In  such  case  the  fundus 
should  then  be  sought  posteriorly  by  carrying  the  internal  finger 
up  into  the  posterior  cul-de-sac  while  external  pressure  is  made  by 
the  external  hand  from  above  (Fig.  781). 

A  posterior  flexion  will  be  readily  differentiated  from  a  version  by 
the  bend  or  angle  on  the  posterior  aspect  of  the  uterus  (Fig.  782). 


Fig.  782. — Diagnosis  of  a  posterior  flexion  of  the  uterus  by  bimanual  palpation. 

(Ashton.) 

In  the  presence  of  a  posterior  displacement  it  should  be  determined 
whether  the  uterus  is  mobile  or  fixed  through  adhesions  by  passing 
the  internal  fingers  high  up  posteriorly  and  by  the  aid  of  the  external 
hand  attempting  to  lift  the  uterus  up. 

After  thoroughly  examining  the  uterus  the  condition  of  the  broad 
and  uterosacral  ligaments  should  be  ascertained.  By  carrying  the 
fingers  up  beside  the  cervix  into  the  lateral  fornices  and  making 
counter-pressure  from  above  the  condition  of  the  broad  ligaments 
may  be  determined,  and  any  pain  on  pressure,  thickening,  or  indura- 
tion noted.  Palpation  of  the  uterosacral  ligaments  through  the  pos- 
terior fornix  may  be  performed  in  like  manner. 

The  tubes  and  ovaries  should  also  be  examined  with  reference  to 
their  size,  shape,  consistency,  sensitiveness,  position,  and  mobility. 
It  is  of  advantage  to  use  the  right  hand  in  palpating  the  right  side 


BIMANUAL   PALPATION 


757 


and  the  left  hand  for  the  left  side.  The  examining  fingers  are  in- 
serted well  up  in  the  lateral  fornix  beside  the  cervix  in  an  upward  and 
backward  direction,  while  the  external  hand  makes  deep  pressure 
downward  through  the  abdominal  wall  on  the  corresponding  side. 
By  altering  the  position  of  the  fingers  of  the  two  hands  from  time  to 
time  the  ovary  and  tube  are  finally  grasped  between  the  opposed 
fingers  (Fig.  783).  Except  where  the  abdominal  walls  are  extremely 
thin  and  the  vagina  is  relaxed,  the  normal  tube  cannot  be  felt,  but, 


Fig.  783. — Examination    of    the    uterine    appendages    by    bimanual    palpation. 

(Ashton.) 


when  enlarged,  it  may  be  readily  recognized  at  a  club-shaped  mass 
gradually  narrowing  down  as  it  approaches  the  uterus.  The  nor- 
mal ovaries,  however,  are  generally  palpable  as  small,  oval  masses, 
somewhat  tender  upon  pressure,  on  each  side  of  the  uterus.  When, 
as  the  result  of  chronic  inflammation,  extensive  adhesive  formation 
has  taken  place  the  tubes  and  ovaries  are  often  matted  together  into 
irregular  masses,  and  it  may  not  be  possible  to  map  them  out  sepa- 
rately. Having  examined  one  side  of  the  pelvis,  the  same  procedure 
is  repeated  upon  the  other  side. 

2.  Recto-abdominal. — The  examiner  stands  facing  the  patient  and 
inserts  the  well-lubricated  index-finger  of  the  left  hand  high  into  the 
rectum.     At  the  same  time  the  external  hand  placed  on  the  abdomen 


758 


THE  PEMALE  GEXERATR'E  ORGANS 


above  the  symphysis  makes  counter-pressure,  while  the  uterus  and 
appendages  are  carefully  palpated  fFig.  784).      Care  must  be  taken, 


Fig.  784. — Recto-abdominal  palpation  of  the  uterus.     (Ashton.) 


Fig.  785. — Recto-abdominal  palpation  of  the  uterus  with  the  latter  drawn  toward 
the  vaginal  outlet  by  means  of  a  tenaculum.     (Ashton.) 

however,  not  to  exert  too  much  force  with  the  fingers  in  the  rectum 
for  fear  of  lacerating  or  otherwise  injuring  the  bowel. 


EXAMINATION  BY   SPECULA  .  759 

By  drawing  the  uterus  well  down  by  means  of  a  pair  of  bullet 
forceps  caught  in  the  cervix,  and  then  performing  recto-abdominal 
palpation,  a  much  more  complete  examination  is  possible  (Fig.  785). 
This  method,  however,  should  never  be  attempted  when  the  uterus  is 
fixed  by  adhesions  or  the  appendages  are  inflamed.  As  a  rule,  general 
anesthesia  is  necessary.  Care  should  always  be  taken  to  replace  the 
uterus  in  its  normal  position  at  the  completion  of  such  an  examination 

EXAMINATION  BY  SPECULA 

By  means  of  suitable  specula  the  mucous  membrane  of  the  entire 
vagina  and  cervix  may  be  directly  inspected.  The  use  of  specula 
furnishes  little  information  outside  of  the  color  and  condition  of  the 


Fig.  786. — Goodell's  vaginal  speculum.     (Ashton.) 

mucous  membrane  and  the  origin  of  a  discharge,  which  is  not  as 
readily  obtainable  by  digital  palpation.  For  gynecological  treat- 
ment and  operative  procedures,  however,  specula  are  indispensable. 


Fig.  787. — Trivalve  vaginal  speculum. 

Instruments. — Numerous  specula  have  been  devised,  such  as  the 
bivalve  (Fig.  786),  the  trivalve  (Fig.  787),  the  cyhndrical,  the  Sims 
(Fig.  788),  Simon's,  the  self-retaining  weighted  speculum,  etc.,  etc. 


760 


THE  FEMALE  GENERATIVE  ORGANS 


For  diagnostic  purposes  the  bivalve  and  the  Sims  specula  are  prob- 
ably most  commonly  employed.  To  prevent  the  anterior  vaginal 
wall  from  obscuring  the  view  when  using  the  Sims  speculum  a  vag- 
inal depressor  is  also  required  (Fig.  789).     A  sponge  holder  (Fig. 


Fig.  788. — Sims'  vaginal  speculum.      (Ashton.) 

790)  and  cotton  wipes  should  be  provided  for  removing  secretions. 

Asepsis. — The  speculum  should  be  sterilized  by  boiling  for  five 
minutes  in  a  i  per  cent,  soda  solution  before  use. 

Position  of  Patient. — When  the  bivalve  or  trivalve  speculum  is 


Fig.  789. — Vaginal  depressor.     (Ashton.) 

employed  the  patient  should  be  in  the  dorsal  position.  In  using  the 
perineal  retractors,  such  as  the  Sims,  the  left  lateral,  or  the  knee- 
chest  position  may  be  employed. 

Preparations  of  Patient. — (See  page  739.) 


Fig.   790. — Sponge  holder  and  swab. 

Technic. —  i.  With  the  Bivalve  Speculum. — The  examiner  stands 
or  sits  facing  the  vulva.  Then,  with  the  labia  well  separated  be- 
tween the  index-  and  middle  fingers  of  the  left  hand,  the  speculum, 
warmed  and  well  lubricated,  is  inserted  into   the  vagina   with   its 


EXAMINATION   BY    SPECULA 


761 


blades  parallel  to  the  vulva  opening  (Fig.  791).     The  speculum  is 
introduced  about  2  inches  (5  cm.)  and  is  then  rotated  so  that  the 


Fig.  791. — Method  of  inserting  the  bivalve  speculum.     (Ashton.) 


Fig.  792. — A'lethod  of  exposing  the  lateral  walls  of  the  vagina  by  means  of  the 
bivalve  speculum.      (Ashton.) 

blades  lie  parallel  with  the  anterior  and  posterior  vaginal  walls.  By 
widely  separating  the  blades  (Fig.  792)  a  view  of  the  cervLx  and  the 
lateral  walls  of  the  vagina  is  obtained.      For  inspection  of  the  ante- 


76. 


THE  FEMALE  GENERATIVE  ORGANS 


rior  and  posterior  vaginal  walls  the  blades  of  the  speculum  are  turned 
so  that  they  lie  parallel  with  the  outlet  of  the  vulva  and  they  are 
then  opened  (Fig.  793).     The  condition  of  the  entire  vaginal  mucous 


Fig.  793. — Method  of  exposing  the  anterior  and  posterior  vaginal  walls  by  means  of 
a  bivalve  speculum.     (Ashton.) 


Fig.  794. — Shows  the  method  of  inserting  Sims'  speculum. 

membrane  may  be  thus  ascertained,  and  inflammatory  conditions, 
a  fistulous  opening,  new  growths,  etc.,  will  be  readily  recognized  if 
present.     If  a  discharge  is  present,  its  origin  should  be  determined. 


EXAMINATION  BY    SPECULA 


763 


Fig.  795. — Showing  the  Sims  speculum  in  place.      (Ashton.) 


Fig.  796. — Method  of  inspecting  the  cervix  by  the  aid  of  the  Sims  speculum  and  a 
vaginal  depressor.     (Ashton.) 


764  THE    FEMALE    GENERATIVE    ORGANS 

The  cervix  is  then  inspected,  noting  its  size  and  shape  and  whether 
it  is  lacerated  or  is  the  seat  of  inflammation,  erosions,  cysts,  or  new 
growths,  and  whether  a  discharge  issues  from  the  external  os.  If 
secretions  obstruct  the  view,  they  should  be  carefully  wiped  away  by 
means  of  cotton  wipes  held  by  a  sponge  holder.  In  some  cases, 
where  the  vagina  is  very  long  and  narrow,  a  clear  view  of  the  cervix 
can  only  be  obtained  by  drawing  it  down  into  the  vagina  by  means  of 
a  tenaculum  or  bullet  forceps. 

2.  With  the  Sims  Speculum. — The  shaft  of  the  speculum  is  grasped 
in  the  operator's  right  hand  while  with  the  left  hand  the  upper 
buttock  is  raised  so  that  the  vulva  is  well  separated.  The  blade  of 
the  speculum,  which  has  been  previously  warmed  and  lubricated, 
is  then  inserted  into  the  vagina  parallel  with  the  cleft  of  the  vulva 
(Fig.  794).  The  blade  is  then  rotated  so  that  it  lies  parallel  with  the 
anterior  and  posterior  vaginal  walls  and  is  further  introduced  until 
its  distal  end  lies  back  of  the  cervix.  By  making  traction  backward 
and  outward  the  perineum  is  retracted  so  that  an  excellent  view  of 
the  anterior  vaginal  wall  and  cervix  is  obtained  (Fig.  795).  Should 
the  anterior  vaginal  wall  obstruct  the  view,  it  may  be  drawn  out  of 
the  way  by  means  of  the  vaginal  retractor  as  shown  in  Fig.  796. 

SOUNDING  THE  UTERUS 

The  uterine  sound,  which  was  formerly  employed  to  a  great  ex- 
tent in  gynecological  diagnosis,  is  now  seldom  used,  as  little  informa- 
tion is  gained  by  its  use,  outside  of  determining  the  length,  size,  and 
consistency  of  the  uterine  cavity,  that  is  not  as  readily  obtainable 
by  other  and  less  dangerous  means.  The  unskilled  use  of  the  uterine 
sound  has  often  led  to  the  introduction  of  septic  material  into  the 
uterus  carried  from  the  vagina  or  cervix,  as  well  as  to  the  infliction 
of  serious  injury  upon  the  uterine  mucous  membrane  and  even  per- 
foration of  that  organ.  To  avoid  these  risks  the  position  of  the 
uterus  should  be  ascertained  before  an  attempt  is  made  to  introduce 
the  sound,  and,  during  the  attempt,  only  gentle  manipulations  of 
the  instrument  should  be  made;  it  should  never  be  used  as  a  means  of 
righting  a  displaced  uterus.  The  sound  should  never  be  introduced 
by  touch  alone,  but  always  with  the  cervix  clearly  exposed  by  means 
of  a  speculum,  and  in  every  case  the  date  of  the  last  menstruation 
should  be  ascertained  beforehand  so  as  not  to  interrupt  a  possible 
pregnancy.  Its  use  is  contraindicated  if  the  uterus  is  infected  or  is 
the  seat  of  a  malignant  disease,  or  if  the  uterine  appendages  are 
involved  in  a  suppurative  disease. 


SOUNDING    THE    UTERUS 


765 


Instruments. — The  operator  will  require  a  vaginal  speculum,  a 
pair  of  bullet  forceps,  cotton  wipes,  a  sponge  holder,  and  a  uterine 
sound  (Fig.  797). 

The  sound  is  made  of  flexible  metal,  about  12  inches  (30  cm.) 
long  and  from  1/12  to  1/8  inch  (2  to  3  mm.)  thick,  with  a  bulbous 
tip.  The  shaft  is  marked  off  in  inches,  and  2  1/2  inches  (6  cm.)  from 
the  distal  end  is  a  small  protuberance  to  indicate  the  normal  depth 
of  the  uterus. 

Asepsis. — The  introduction  of  a  sound  or  any  instrument  into  the 
uterus  should  be  regarded  as  a  surgical  operation  and  should  be  carried 


Fig.  797. — Instruments  for  sounding  the  uterus,      i,  Garrigues'  weighted  specu- 
lum; 2,  dressing  forceps;  3,  tenaculum;  4,  uterine  sound. 


out  with  every  aseptic  detail.  All  the  instruments  should  be  boiled 
for  five  minutes  in  a  i  per  cent,  soda  solution.  The  external  genitals 
should  be  thoroughly  cleansed  with  soap  and  water  followed  by  a 
I  to  2000  bichlorid  solution  and  the  vagina  should  be  douched  with 
some  antiseptic.  The  operator's  hands  are  cleansed  as  thoroughly 
as  for  any  operation. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
position. 

Technic. — The  operator  sits  facing  the  vulva  and,  after  separating 
the  labia,  introduces  the  speculum.  The  anterior  lip  of  the  cervix 
is  then  seized  by  means  of  bullet  forceps  and,  after  being  pulled  down 
into  view,  is  thoroughly  wiped  off  with  a  cotton  swab  soaked  in  a 


7C6 


THE  PEMALE  GENERATrv:E  ORGANS 


I  to  2000  bichlorid  solution.  The  sound  with  its  distai  3  inches  (7.5 
cm.)  bent  in  a  slight  forward  curve  is  grasped  lightly  between  the 
thumb  and  forefinger  of  the  right  hand  and  is  introduced  into  the 
external  os,  being  careful  not  to  touch  any  portion  of  the  vagina.  By 
gently  depressing  its  handle  the  sound  should  readily  glide  up  the 
canal  to  the  fundus.  If  the  point  is  arrested  by  catching  in  a  fold  of 
mucous  membrane  or  at  the  internal  os,  gentle  manipulation  will 
usually  result  in  its  passage — force  should  never  he  employed. 


Fig.  798. — Showing  the  method  of  estimating  the  length  of  the  uterus  by  means  of 

the  uterine  sound. 

Sometimes,  when  the  cervix  is  bent  forward,  the  sound  may  be 
more  readily  passed  if  it  is  started  with  the  concavity  of  its  curve 
turned  backward  and,  as  soon  as  it  becomes  arrested,  rotating  it  for- 
ward. When  the  tip  of  the  instrument  reaches  the  fundus,  the  opera- 
tor's right  index-finger  should  be  slid  along  the  shaft  of  the  instru- 
ment until  it  comes  in  contact  with  the  cervix  for  the  purpose  of  in- 
dicating the  depth  of  the  canal  when  the  instrument  is  removed 
(Fig.  798). 


DIGITAL  PALPATION  OF  THE  UTERINE  CAVITY 

Digital  exploration  of  the  interior  of  the  uterus  is  occasionally 
required  in  the  diagnosis  of  intrauterine  growths  or  retained  prod- 


DIGITAL  PALPATION   OF   THE   UTERINE    CAVITY  767 

ucts  of  conception  which  are  not  revealed  by  other  methods  of 
examination.  With  the  finger  in  the  cavity  of  the  uterus  it  is  possible 
to  determine  whether  the  uterus  is  empty  or  not,  the  length  and 
direction  of  the  canal,  and  the  thickness,  consistency,  and  other 
characteristics  of  the  endometrium. 

Digital  exploration  necessitates  a  thorough  preliminary  dilata- 
tion of  the  cervix,  except  in  puerperal  cases,  and  should,  therefore, 
be  considered  in  the  same  light  as  a  surgical  operation.  It  should 
not  be  attempted  until  the  possibility  of  pregnancy  has  been  excluded 
by  determining  the  date  of  the  last  menstruation  and  by  a  careful 
examination. 


Fig.  799. — Digital  exploration  of  the  uterine  cavity.      (Ashton.) 

Instruments. — Instruments  for  dilating  the  cervix  are  required. 
These  include  a  vaginal  speculum,  a  pair  of  dilators,  sponge  holders, 
and  two  bullet  forceps.     (See  Fig.  851.) 

Asepsis. — Strict  aseptic  precautions  should  be  observed.  The 
external  genitals  are  washed  with  soap  and  water,  followed  by  a 
I  to  2000  bichlorid  of  mercury  solution.  The  vagina  is  scrubbed 
with  soap  and  water  by  means  of  a  sponge  on  a  holder  and  is  then 
douched  with  an  antiseptic  solution.  The  instruments  are  boiled 
for  five  minutes  in  a  i  per  cent,  soda  solution  and  the  operator's 
hands  are  prepared  with  the  same  care  as  for  any  operation. 

Position  of  Patient. — The  lithotomy  position  is  employed. 


768 


THE  FEMALE  GENERATR^E  ORGANS 


Anesthesia. — General  anesthesia  is  required  except  in  postpartum 


cases. 


Technic. — The  cervix  is  first  dilated  sufficiently  to  admit  the 
operator's  finger  (see  page  803).  The  index-finger  of  the  right  hand 
or,  where  possible,  as  in  postpartum  cases,  the  index-  and  middle 
fingers  are  then  passed  into  the  uterus,  while,  with  the  left  hand  on 
the  abdomen,  the  operator  presses  down  upon  the  fundus  uteri,  so 
as  to  bring  the  uterus  within  reach  of  the  internal  fingers  (Fig.  799). 
The  interior  of  the  uterus  is  then  systematically  explored  by  the  in- 
ternal fingers. 


Fig.  800. — Instruments  for  an  exploratory  vaginal  section,  i,  Garrigues' 
weighted  speculum;  2,  sponge  holder;  3,  tenaculum;  4,  thumb  forceps;  5,  sharp- 
pointed  scissors;  6,  artery  clamps;  7,  needle  holder;  8,  needles;  9,  No.  2  catgut. 


THE  EXAMINATION  OF  SECTIONS  AND  SCRAPINGS  FROM 

THE  UTERUS 

To  determine  the  nature  of  a  suspicious  growth  a  portion  should 
be  excised  for  examination.  The  method  of  doing  this  has  already 
been  described  (page  254).  Where  the  interior  of  the  uterus  is  the 
seat  of  suspected  disease,  scrapings  from  the  endometrium  should 
be  collected  by  a  thorough  curettage  for  examination  (see  page  807). 

EXPLORATORY  INCISION 


Direct  palpation  of  the  pelvic  structures  is  sometimes  required  in 
the  diagnosis  of  obscure  pelvic  conditions.      It  may  be  accomplished 


EXPLORATORY   INCISION 


769 


by  means  of  an  abdominal  incision  or  through  a  small  opening  made 
in  the  cul-de-sac  of  Douglas.  The  latter  method  is  preferable,  as  it 
is  not  a  dangerous  operation,  and  the  recovery  of  the  patient  is  more 
rapid  than  when  an  abdominal  section  is  performed.  The  operator 
should  be  prepared,  however,  to  perform  any  operative  procedures, 
such  as  draining  a  pus  sac,  removing  suppurating  tubes,  or  opening 
the  abdomen,  if  the  findings  indicate  it. 

Instruments. — There  will  be  required  a  weighted  vaginal  specu- 
lum, sponge  holders,  bullet  forceps,  toothed  thumb  forceps,  sharp- 


FiG.  801. — First  step  in  performing  a  posterior  vaginal  section,  opening  into  the 

posterior  cul-de-sac. 


pointed  curved  scissors,  artery  clamps,  curved  cutting-edged  needles, 
a  needle  holder,  and  No.  2  catgut  (Fig.  800). 

Asepsis. — The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution.  The  external  genitals  are  scrubbed  with  soap 
and  water  followed  by  a  i  to  2000  bichlorid  solution,  and  the  vagina 
is  cleansed  by  first  washing  with  soap  and  water  and  then  by  means 
of  an  antiseptic  douche.  The  operator's  hands  are  sterilized  in  the 
usual  way. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
position. 
49 


770 


THE  FEMALE  GENERATIVE  ORGANS 


Fig.  802. — Shows  the  posterior  cul-de-sac  opened. 


Fig.  803. — Shows  the  method  of  palpating  a  tumor  through  an  incision  into  the 

posterior  cul-de-sac. 


VAGINAL   IRRIGATIONS  77 1 

Preparation  of  Patient. — The  patient  is  prepared  for  general 
anesthesia  (see  page  2)  and  the  bowels  and  bladder  should  be 
empty  at  the  time  of  operation. 

Anesthesia. — General  anesthesia  is  employed. 

Technic. — The  vaginal  speculum  is  placed  in  the  vagina  and  the 
posterior  lip  of  the  cervix  is  seized  in  bullet  forceps  which  are  given 
to  an  assistant  to  hold.  The  operator  then  picks  up  the  posterior 
vaginal  wall  by  means  of  thumb  forceps  at  a  point  in  the  mid-line, 
just  back  of  where  it  is  reflected  from  the  cervix,  and  with  a  pair  of 
scissors  makes  a  transverse  incision  about  i  inch  (2.5  cm.)  long 
through  the  vaginal  wall  (Fig.  801).  The  vaginal  wall  posterior  to 
the  incision  is  then  separated  by  blunt  dissection  from  the  under- 
lying peritoneum  for  a  short  space  (Fig.  802).  The  peritoneum  thus 
exposed  is  then  picked  up  and  a  transverse  opening,  sufficiently 
large  to  admit  the  fingers,  is  made  in  it.  Through  this  opening  the 
pelvic  structures  may  be  thoroughly  palpated  by  the  finger  (Fig. 
803),  and  if  desired  the  appendages  may  be  brought  down  to  view 
and  inspected. 

At  the  completion  of  the  operation  the  opening  in  the  peritoneum 
and  that  in  the  vaginal  wall  are  closed  by  a  few  catgut  sutures. 

Therapeutic  Measures 

VAGINAL  IRRIGATIONS 

Vaginal  irrigation,  or  douching,  may  be  employed  for  simple 
cleansing  purposes,  as  in  leucorrhea  or  in  preparation  for  operative 
procedures,  for  the  purpose  of  bringing  soothing,  astringent,  or  anti- 
septic solutions  in  contact  with  diseased  vaginal  or  cervical  mucous 
membrane,  and  as  a  means  of  applying  heat  to  the  pelvic  organs  to 
relieve  congestion  or  inflammation,  to  hasten  involution  after  labor, 
to  control  uterine  hemorrhage,  etc.  In  pregnancy  and  during 
m.enstruation  douches  should  be  used  with  caution. 

Apparatus.— There  will  be  required  a  large  glass  irrigating  jar  or 
douche  bag,  a  bath  thermometer,  6  feet  (180  cm.)  of  rubber  tubing, 
1/4  inch  (6.  mm.)  in  diameter,  leading  from  the  reservoir  to  the 
douche  nozzle,  a  glass  vaginal  douche  nozzle,  and  a  douche  pan  with  a 
spout  to  which  is  attached  a  piece  of  rubber  tubing  sufficiently  long 
to  convey  the  waste  fluid  to  a  slop  pail  (Fig.  804). 

The  douche  nozzle  should  preferably  be  of  glass  without  any  curve 
and  having  perforations  on  the  sides  but  with  none  at  the  end  (Fig.  805) . 


772 


THE  FEMALE  GENERATWE  ORGANS 


With  such  an  instrument  there  is  little  danger  of  the  solution  entering 
the  uterus  in  cases  of  a  patulous  cervix. 

Asepsis. — The  greatest  care  should  be  taken  against  infection 
especially  in  puerperal  cases.  The  apparatus  should,  therefore,  be 
boiled  for  five  minutes  in  plain  water  and  the  thermometer  should  be 


Fig.   804. — Apparatus  for  vaginal  douching. 

sterilized  by  immersion  in  a  i  to  500  bichlorid  of  mercury  solution, 
after  which  it  is  rinsed  in  sterile  water.  The  attendant's  hands  should 
be  cleansed  in  the  usual  way  and  the  external  genitals  should  be 
washed  with  soap  and  water  followed  by  a  i  to  2000  bichlorid  solution. 
When  the  patient  administers  the  douches  herself,  the  dangers  of 


Fig.  805. — Enlarged  view  of  a  glass  vaginal  douche  nozzle. 

infection  and  the  proper  means  of  avoiding  it  should  be  carefully 
explained  to  her. 

Solutions  Used. — Among  the  many  solutions  used  for  vaginal 
injection  are  the  following:  Plain  sterile  water;  normal  salt  solu- 
tion— salt  5i  (4  gm-)  to  the  pint  (500  c.c.)  of  boiled  water — boric 
acid,  2  per  cent.;  thymol  i  to  1000;  lysol  i  per  cent.;  creolin  i  per 
cent.;  tannic  acid  o'l  (4  gm.)  to  the  quart  (liter);  alum  acetate  oi 
(4  gm.)   to  the  quart  (liter);  permanganate  of  potash   i   to  2000; 


VAGINAL   nmiGATIONS 


773 


bichlorid  of  mercury  i  to  5000;  carbolic  acid  i  per  cent.,  etc.  The 
use  of  poisonous  drugs,  such  as  the  latter  two,  should  he  followed  by  a 
douche  of  sterile  water  or  saline  to  avoid  any  danger  of  absorption. 

Temperature. — Ordinarily  the  irrigation  is  given  at  a  tempera- 
ture of  100°  to  105°  F.  (38°  to  41°  C).  When  the  stimulating  and 
vascular  constricting  effect  of  heat  is  desired,  however,  the  temp- 
erature should  be  from  115°  to  120°  F.  (46°  to  49°  C). 

Quantity. — At  least  i  gallon  (4  liters)  of  solution  should  be  used 
at  a  time.     If  it  is  desired  to  obtain  a  prolonged  effect  from  the  heat, 


Fig.  806. — Showing  the  correct  (a)  and  the  incorrect  {b)  method  of  giving  a  vaginal 

douche.     (Ashton.) 

several  gallons  may  be  used  over  a  period  of  fifteen  to  thirty  minutes. 

Height  of  Elevation. — This  is  important,  since,  if  the  reservoir  is 
elevated  too  high,  the  pressure  will  be  so  gre.at  that  solution  may  be 
forced  into  the  uterus.  An  elevation  of  2  to  3  feet  (60  to  90  cm.)  is 
amply  sufficient. 

Frequency. — This  will  depend  upon  the  purposes  of  the  douche 
from  once  a  day  to  three  or  more  times  daily. 

Position  of  Patient. — The  patient  lies  in  bed  on  a  douche  pan  in 
the  dorsal  position,  with  the  knees  flexed,  or  else  recumbent  in  a  bath 
tub.  The  douche  should  not  be  taken  with  the  patient  sitting  on  the 
toilet. 

Technic. — The  labia  are  widely  separated  with  the  fingers  of  the 
left  hand  and  with  the  right  hand  the  nozzle  is  introduced  into  the 
vagina,  first,  however,  allowing  the  solution  to  flow  in  order  to  expel 


774  THE  FEMALE  GENERATIVE  ORGANS 

any  air  or  cold  fluid.  The  desired  amount  of  solution  is  then  per- 
mitted to  enter  the  vagina  which  balloons  up  under  the  influence  of 
the  distention  and  thus  allows  the  solution  to  come  in  contact  with 
its  entire  surface  (Fig.  806). 

In  cases  of  a  relaxed  vagina,  it  is  necessary  to  compress  the  vaginal 
outlet  about  the  douche  tube  in  order  to  obtain  this  distention. 
This  procedure  should,  however,  be  used  with  caution  in  puerperal 
cases,  for,  if  the  intravaginal  pressure  be  too  great,  some  of  the 
solution  will  necessarily  be  forced  into  the  uterus.  During  the  irri- 
gation care  must  be  taken  to  protect  the  patient's  body  from 
cold  by  suitable  covering. 

LOCAL  APPLICATIONS  TO  THE  VAGINA  AND  CERVIX 

Local  appHcations  are  employed  in  treating  inflammations  of  the 
vagina  and  the  vaginal  portion  of  the  cervix.  They  may  be  made  by 
means  of  cotton-tipped  applicators  or  by  tampons  (see  page  778). 


Fjg.  807. — Instruments  for  making  local  applications  to  the  vagina,      i,  Bivalve 
speculum;  2,    applicator. 

The  former  method  should  be  employed  when  it  is  desired  to  medi- 
cate locahzed  areas  of  inflammation  or  ulceration  or  to  employ 
strong  solutions. 

Instruments. — There  will  be  required  a  bivalve  vaginal  speculum 
and  a  metal  applicator  or  a  pair  of  dressing  forceps  (Fig.  807). 

Asepsis. — The  instruments  are  boiled  in  a  i  per  cent,  soda  solu- 
tion for  five  minutes  and  the  external  genitals  are  cleansed  with  soap 
and  water  followed  by  a  i  to  2000  bichlorid  of  mercury  solution. 
The  operator's  hands  should  likewise  be  clean. 

Solutions  Used. — Tincture  of  iodin,  silver  nitrate  gr.  xx  to  xxx 
(1.3  to  2  gm.)  to  the  ounce  (30  c.c),  argyrol  50  per  cent.,  copper 
sulphate  gr.  v  to  xx  (0.3  to  1.3  gm.)  to  the  ounce  (30  c.c),  zinc  sul- 
phate gr.  V  to  XX  (0.3  to  1.3  gm.)  to  the  ounce  (30  c.c),  etc.,  are 
among  the  solutions  generally  employed. 


LOCAL   APPLICATIONS   TO  THE  VAGINA   AND    CERVIX 


775 


Frequency.^ — Applications  may  be  made  every  three  or  four  days. 

Position  of  Patient. — The  patient  should  be  upon  a  firm  table  in 
the  dorsal  position. 

Technic. — The  diseased  area  is  exposed  by  means  of  a  speculum 
and,  after  removing  any  mucus  or  secretion,  the  surface  it  is  desired 
to  medicate  is  wiped  dry.  An  applicator  or  dressing  forceps  wrapped 
with  cotton  is  then  dipped  in  the  solution  and  the  saturated  swab  is 
thoroughly  rubbed  over  the  diseased  area.  Following  this  a  light 
vaginal  tampon  is  inserted  and  allowed  to  remain  in  place  twelve  to 
twenty-four  hours. 

APPLICATION  OF  POWDERS  TO  THE  VAGINA 

Powders  are  sometimes  employed  with  success  in  place  of  liquids 
in  the  treatment  of  chronic  vaginitis,  especially  if  ulcerated  surfaces 
are  present. 


Fig.  808. 


-Instruments  for  the  application  of  powders  to  the  vagina, 
speculum;  2,  dressing  forceps;  3,  powder  blower. 


I,  Bivalve 


Instruments.— A  vaginal  speculum,  dressing  forceps,  and  a 
powder  blower  are  required  (Fig.  808). 

Formulary.— Soothing  or  astringent  powders,  such  as  boric  acid, 
zinc  oxid,  bismuth  subnitrate,  calomel,  tannic  acid,  glycerole  of  tannin, 
acetanihd,  alone  or  in  combination,  are  frequently  employed. 

Position  of  Patient.— The  patient  should  be  in  the  dorsal  posture. 


776 


THE  FEMALE  GENERATIVE  ORGANS 


Technic. — The  vagina  is  first  well  cleansed  with  a  douche.  A 
speculum  is  then  inserted  and,  by  means  of  a  cotton  swab  held  in  a 
dressing  forceps,  the  mucous  membrane  is  thoroughly  dried.  The 
entire  inflamed  surface  is  then  coated  with  the  desired  powder  applied 
by  means  of  the  powder  blower.  A  light  tampon  is  finally  inserted 
and  is  left  in  place  for  twenty-four  hours. 

VAGINAL  TAMPONS 

Vaginal  tampons  are  used  for  a  variety  of  purposes,  namely,  to 
bring  medication  in  contact  with  the  vagina  or  the  cervix  in  the  treat- 


FiG.  809. — Showing  the  method  of  making  a  cotton  vaginal  tampon. 
(Kelly  and  Noble.) 

ment  of  inflammations  involving  these  structures,  to  protect  and 
keep  separated  inflamed  or  ulcerated  vaginal  walls,  to  apply  glycerin 


VAGINAL    TAMPONS 


777 


for  its  depleting  effect  upon  the  uterus  and  pelvic  organs,  to  support 
a  prolapsed  ovary,  for  the  purpose  of  stretching  adhesions  or  sup- 
porting the  uterus  by  distention  of  the  vagina  and  fornices,  and  alone 
or  in  combination  with  the  uterine  pack  to  control  hemorrhage  from 
the  uterus. 

Tampons  should  not  be  left  in  place  more  than  twenty-four  hours, 
as  they  tend  to  become  foul  and  offensive,  and  strings  should  always 
be  attached  so  that  they  may  be  removed  by  the  patient.  The 
patient  should,  of  course,  be  informed  of  the  exact  number  of  tam- 
pons inserted. 

Instruments. — Bivalve  and  Sims'  specula  and  dressing  forceps 
are  required. 

The  Tampon. — Tampons  are  made  of  absorbent  cotton,  lambs' 
wool,  or  gauze.     For  carrying  medication  absorbent  cotton  is  prefer- 


FiG.  8io. — Vaginal  tampons  in  position. 

able,  while  for  purposes  of  support  lambs'  wool  or  gauze,  having  more 
body,  are  best. 

The  cotton  tampon  is  made  by  cutting  a  flat  layer  of  absorbent 
cotton  into  an  oblong  shape,  placing  a  heavy  silk  string  about  14 
inches  (35  cm.)  long,  across  one  end  as  shown  in  Fig.  809,  and  rolling 
the  cotton  about  the  string.  On  tying  the  string  the  two  ends  of  the 
cotton  roll  are  brought  together  and,  at  the  same  time,  the  string  is 
buried  in  and  securely  fastened  to  the  cotton. 

Lambs'  wool  tampons  may  be  made  in  the  same  manner  or  a  silk 
string  may  be  simply  tied  to  the  center  of  a  wad  of  the  wool. 

A  gauze  tampon  should  consist  of  a  single  piece  of  gauze  .3  feet 
(90  cm.)  or  more  long,  depending  on  the  capacity  of  the  vagina  and  the 


778 


THE  FEMALE  GENERATWE  ORGANS 


firmness  with  which  it  is  to  be  packed,  and  folded  to  a  width  of  about 
2  inches  (5  cm."). 

The  Medicated  Tampon. — The  tampon  is  made  as  above  de- 
scribed and  is  then  saturated  with  the  desired  medication.  For  this 
purpose  the  following  drugs  are  employed:  Ichthyol  and  glycerin  25 
per  cent.,  boroglycerid,  glycerite  of  tannic  acid  20  per  cent.,  argyrol 
10  to  25  per  cent.,  protargol  2  per  cent,  etc.  When  indicated  the 
tampon  may  be  covered  with  some  of  the  powders  mentioned  on  j^age 
775  in  place  of  these  solutions. 

Asepsis. — The  instruments  should  be  boiled  and  the  tampons 
thoroughly  sterilized.     The  external  genitals  are  washed  with  soap 


Fig.  811. — Shows  the  method  of  packing  the  vagina  with  the  patient  in  the  Sims 

position. 

and  water  followed  by  a  i  to  2000  bichlorid  of  mercury  solution.     The 
operator's  hands  are  cleansed  in  the  usual  way. 

Position  of  Patient. — For  inserting  the  medicated  tampon  the 
patient  may  be  in  the  dorsal  posture,  but  when  it  is  desired  to  thor- 
oughly pack  the  vaginal  vault  for  the  purposes  of  support  and  to  con- 
trol hemorrhage  the  Sims  or  the  knee-chest  posture  is  preferable. 

Prepgirations  of  Patient. — The  bladder  and  bowels    should  be. 
empty.     Any  clots  or  secretions  are  \M*ped  from  the  vagina  and  the 
entire  vagina  is  then  swabbed  out  with  a  i  to  2000  bichlorid  of  mer- 
curv  solution. 


THE    INTRAUTERINE    DOUCHE  779 

Technic. — For  applying  a  medicated  tampon  a  bivalve  speculum 
is  inserted  and  the  tampon,  soaked  in  the  medicament,  is  carried  in 
dressing  forceps  to  the  desired  spot.  A  wool  tampon  is  then  inserted 
to  retain  the  first  one  in  position  and,  while  the  tampons  are  held 
securely  in  place  by  means  of  the  dressing  forceps,  the  speculum  is 
removed,  care  being  taken  that  the  strings  attached  to  the  tampons 
are  left  hanging  from  the  vagina  (Fig.  8io). 

The  tampon  is  to  be  removed  by  the  patient  within  twenty-four 
hours,  at  which  time  a  cleansing  douche  should  be  taken. 

To  thoroughly  pack  the  vagina,  as  is  necessary,  for  example,  for 
the  control  of  hemorrhage,  the  patient  being  in  the  Sims  or  the  knee- 
chest  posture,  a  Sims  speculum  is  inserted  and  the  posterior  vaginal 
waU  is  put  upon  the  stretch.  Then,  by  means  of  a  pair  of  dressing 
forceps,  the  entire  vagina  is  thoroughly  tamponed  with  a  strip  of 
gauze,  beginning  with  the  posterior  vaginal  fornix,  then  filling  the 
lateral  and  anterior  fornices,  and,  as  the  rest  of  the  vagina  is  packed, 
gradually  withdrawing  the  speculum  (Fig.  8ii).  A  T-bandage  is 
then  applied  to  retain  the  pack  in  place.  Such  a  pack  properly 
inserted  wiU  control  any  ordinary  hemorrhage  from  a  nonpuerperal 
uterus,  but  in  severe  hemorrhages  and  in  postpartum  cases  the 
uterus  also  should  be  tamponed  (page  786). 

Removal  of  the  packing  in  twelve  or  twenty-four  hours  should  be 
followed  by  a  cleansing  douche. 

THE  INTRAUTERINE  DOUCHE 

Uterine  douches  are  employed  in  the  treatment  of  septic  condi- 
tions affecting  the  uterus,  to  control  hemorrhage,  and  for  cleansing  the 
uterus  after  curettage  and  other  intrauterine  operations.  They  are 
more  dangerous  than  vaginal  douches,  and  certain  precautions  in  their 
use  are  necessary.  They  should  always  be  given  by  the  physician 
himself  and  in  their  use  the  same  care  and  attention  to  cleanliness 
should  be  observed  as  in  any  operative  procedure.  It  is  absolutely 
essential  that  a  free  and  unimpeded  return  of  the  solution  be  provided 
by  having  the  cervix  well  dilated  or  by  employing  a  return-flow  irri- 
gating nozzle,  otherwise  there  is  danger  of  overdistention  of  the  uterus 
with  resulting  shock  or  of  the  fluid  being  forced  into  the  uterus 
through  the  tubes.  Furthermore,  the  use  of  poisonous  drugs,  such  as 
carbolic  acid  or  hichlorid  of  mercury,  should  always  be  followed  by  an 
intrauterine  irrigation  of  sterile  water  or  of  normal  salt  solution. 

Apparatus. — There  will  be  required  a  glass  irrigating  jar  or  a  large 
douche  bag,  a  thermometer,  6  feet  (180  cm.)  of  rubber  tubing,  1/4 


78o 


THE  FEMALE  GENERATIVE  ORGANS 


inch  (6  mm.)  in  diameter,  connecting  the  reservoir  and  the  douche 
nozzle,  a  douche  pan  with  a  spout  to  which  is  attached  a  piece  of  rub- 
ber tubing  sufficiently  long  to  convey  the  returning  fluid  to  a  waste 
pail  (see  Fig.  804). 

There  are  several  forms  of  intrauterine  douche  nozzles.     When  the 
cervix  is  widely  dilated,  as  in  postpartum  cases,  a  curved  glass  nozzle 


Fig.  812. — Glass  intrauterine  douche  nozzle. 

with  the  openings  upon  the  sides,  such  as  the  Chamberlain  tube  (Fig. 
812),  is  sufficient. 

In  other  cases  it  is  necessary  to  employ  some  form  of  return-flow 
nozzle.     The  Fritsch-Bozeman  nozzle  (Fig.  813)  is  the  safest  of  these. 


Fig.  813. — Fritsch-Bozeman  return-flow  uterine  douche  nozzle.      (Bandler.) 

It  consists  of  an  outer  tube  fenestrated  near  the  tip,  with  a  second 
opening  upon  the  under  surface  of  the  instrument  near  its  lower  end 
for  the  return  flow.  Inside  this  outer  tube  is  a  smaller  inflow  tube. 
This  instrument  requires  some  dilatation  of  the  cervix,  however. 


catheter.      (Ashton.) 


before  it  can  be  introduced  and  where  this  is  lacking  a  smafler  instru- 
ment, such  as  Talley's  intrauterine  catheter  (Fig.  814),  may  be 
employed.  The  latter  consists  of  a  curved  metal  catheter  with  two 
heavy  wires  on  its  under  surface,  which  may  be  expanded  or  closed  by 
turning  a  small  thumb-screw.  The  catheter  is  introduced  into  the 
uterus  with  the  wires  lying  close  to  the  catheter  and,  when  in  the 


THE    INTRAUTERINE    DOUCHE 


781 


uterus,  the  wires  are  expanded,  thereby  dilating  the  cervix  sufficiently 
to  permit  a  return  of  the  injected  solution. 

Instruments. — In  addition  to  the  above  apparatus  a  vaginal 
speculum,  a  sponge  holder,  and  a  pair  of  bullet  forceps  are  required 
(Fig.  815). 

Asepsis. — The  apparatus  and  instruments  should  be  sterilized  by 
boiling  and  the  thermometer  by  immersion  in  a  i  to  500  bichlorid  of 
mercury  solution  followed  by  rinsing  in  sterile  water.  The  external 
genitals  are  first  washed  with  soap  and  water  and  then  with  a  i  to 
2000  bichlorid  of  mercury  solution.     The  vagina  is  cleansed  by  means 


Fig.  815. — Instruments  for  intrauterine  douching,     i,  Garrigues'  weighted  specu- 
lum; 2,  sponge  holder;  3,  tenaculum. 


of  a  I  to  5000  bichlorid  of  mercury  douche,  followed  by  sterile  water. 
The  operator's  hands  are  sterilized  in  the  usual  way. 

Solutions  Used. — Plain  sterile  water,  normal  salt  solution— salt 
3i  (4  gm.)  to  the  pint  (500  c.c.)  of  water,  i  to  10,000  to  i  to  5000 
bichlorid  of  mercury,  50  per  cent,  alcohol,  0.5  per  cent,  solution  of 
lysol,  0.5  per  cent,  solution  of  creolin,  silver  nitrate  i  to  1000,  etc., 
etc.,  are  among  the  solutions  employed. 

Temperature. — Ordinarily  the  temperature  of  the  solution  is 
about  105°  F.  (41°  C).  Where  the  stimulating  and  constricting  effect 
of  heat  is  desired  the  temperature  of  the  solution  should  be  115°  to 
120°  F.  (46°  to  49°  C). 

Quantity. — About  i  quart  (i  liter)  of  solution  is  used  at  a  time. 


78: 


THE  FEMALE  GENERATIVE  ORGANS 


Rapidity  of  Flow. — The  fluid  should  not  be  allowed  to  enter  the 
uterus  more  rapidly  than  it  can  escape,  otherwise  there  is  danger  of  its 


Fig.  8i6. — Inserting  the  douche  nozzle  when  the  cervix  is  well  dilated. 

being  forced  into  the  tubes.     Therefore,  the  reservoir  should  not  be 
elevated  more  than  2  feet  (60  cm.). 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  position. 


Fig.  817. — Method  of  giving  an  intrauterine  douche  in  a  postpartum  case. 

Technic. — If  the  cervix  is  well  dilated  so  that  the  entrance  of  the 
douche  nozzle  is  not  interfered  with,  the  latter  may  be  inserted  by 
touch  alone,  as  follows :    One  or  two  fingers  of  the  left  hand  are  passed 


THE    INTRAUTERINE    DOUCHE 


783 


into  the  vagina  and  the  external  os  is  thus  located.  The  douche 
nozzle,  with  the  solution  flowing  so  as  to  avoid  injecting  any  air,  is 
then  inserted  into  the  uterus  by  the  right  hand,  being  guided  through 
the  cervix  by  the  fingers  of  the  left  hand  (Fig.  816).  The  nozzle  is 
then  gently  passed  to  the  fundus  of  the  uterus  and  the  cavity  is  thor- 
oughly irrigated.  The  return  flow  must  be  carefully  watched  to  see 
that  it  is  not  obstructed.  It  is  well  to  place  the  left  hand  exter- 
nally over  the  fundus  uteri  in  puerperal  cases  to  prevent  any  possible 
overdistention  of  the  uterus  and  opening  up  of  the  sinuses  (Fig.  817). 


Fig.  818. 


-Shows  the  method  of  giving  an  intrauterine  douche  with  a  return-flow 
nozzle. 


To  introduce  the  douche  nozzle  by  sight,  the  posterior  vaginal  wall 
is  retracted  by  means  of  a  speculum,  and,  if  the  cervix  is  not  readily 
accessible,  it  is  drawn  down  into  the  vagina  by  means  of  bullet  forceps 
caught  in  its  anterior  lip.  The  cervix  is  then  wiped  off  by  means  of  a 
swab  on  a  sponge  holder  wet  with  a  i  tp  2000  bichlorid  of  mercury 
solution,  and  a  return-flow  nozzle  is  inserted  by  direct  sight,  taking 
care  to  have  the  solution  first  flowing  (Fig.  818).  In  inserting  the 
nozzle  extreme  gentleness  should  be  used  to  avoid  injuring  the  tissues 
or  possibly  perforating  the  uterus.  The  latter  accident  has  happened 
frequently  enough  to  warrant  this  caution. 


INTRAUTERINE  APPLICATIONS 

The  application  of  drugs  with  an  astringent  or  caustic  action  to  the 
mucous  membrane  of  the  uterus  is  employed  in  the  treatment  of  endo- 


■84 


THE  FEMALE  GENERATWE  ORGANS 


metritis  alone  or  in  conjunction  with  curettage.  The  best  results  are 
obtained,  however,  when  intrauterine  applications  are  used  after  a 
preliminary  curettage. 

The  indiscriminate  employment  of  intrauterine  applications 
should  be  condemned,  as  they  often  do  more  harm  than  good.  They 
should  only  be  employed  in  cases  where  thorough  asepsis  can  be 
obtained,  and  then  only  with  the  cervix  sufficiently  dilated  to  allow 
thorough  subsequent  drainage.  The  procedure,  therefore,  is  one  that 
rises  to  the  dignity  of  an  operation  and  should  never  be  attempted 
as  a  part  of  the  office  treatment. 


Fig.  819. — Instruments    for    making    intrauterine    applications,      i,    Garrigues 
weighted  speculum;  2,  sponge  holder;  3,  tenaculum;  4,  applicator. 


The  position  and  size  of  the  uterus  and  the  condition  of  the  other 
pelvic  organs  must  be  determined  by  bimanual  examination  before- 
hand. In  the  presence  of  adnexal  involvement  or  other  complications 
intrauterine  applications  are  contraindicated. 

Instruments. — There  should  be  provided  a  vaginal  speculum, 
sponge  holders,  bullet  forceps,  and  two  uterine  applicators  (Fig.  819). 

Asepsis. — The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution.  The  external  genitals  are  washed  with  soap  and 
water  followed  by  a  i  to  2000  bichlorid  solution.  The  vagina  is 
douched  with  a  i  to  5000  bichlorid  of  mercury  solution  followed  by 
sterile  water.  The  operator's  hands  are  likewise  sterilized  as  for  any 
operation. 


INTRAUTERINE    APPLICATIONS 


78: 


Solutions  Used. — Sulphate  of  zinc  5  to  10  per  cent.,  chlorid  of  zinc 
5  to  10  per  cent.,  silver  nitrate  5  to  10  per  cent.,  per  chlorid  of  iron  5 
per  cent.,  ichthyol  5  to  10  per  cent.,  tincture  of  iodin  50  per  cent, 
Chinrchill's  solution  of  iodin,  pure  carbohc  acid,  etc.,  etc.,  may  be 
employed. 

Position  of  Patient. — The  patient  is  placed  in  the  dorsal  position. 

Technic. — The  vaginal  speculum  is  inserted  and  the  cervix  is 
drawn  down  into  view  by  means  of  bullet  forceps  which  seize  the  ante- 
rior lip.     Any  secretion  or  collection  of  mucus  is  then  wiped  away 


Fig.  820. — Shows  the  method  of  making  an  intrauterine  application. 

from  the  external  osby  means  of  a  swab  soaked  in  a  i  to  2000  bichlorid 
solution,  and  the  cervix  is  dilated  if  necessary  (see  page  803).  A 
small  thin  layer  of  dry  cotton  is  then  securely  wound  round  an  appli- 
cator, taking  care  that  the  tip  of  the  instrument  is  well  covered.  The 
swab  thus  fashioned  is  to  be  of  such  size  that  it  will  readily  pass  the 
cervix.  The  applicator  is  curved  to  the  shape  of  the  canal  and  is 
passed  into  the  uterus  for  the  purpose  of  removing  any  secretions  and 
thus  allow  the  solution  to  come  in  contact  with  all  portions  of  the 
mucous  membrane.  A  second  applicator,  similarly  wrapped  with 
cotton,  is  dipped  in  the  solution.  Any  excess  of  fluid  is  squeezed 
from  the  cotton  and  the  appHcation  is  then  made  to  the  interior  of  the 
uterus,  carrying  the  cotton-tipped  applicator  well  up  to  the  fundus 
and  moving  the  instrument  about  in  the  cavity  (Fig.  820).  A  vaginal 
tampon  is  finally  inserted,  which  is  removed  in  twenty-four  hours. 
The  patient  should  remain  quiet  for  a  day  or  two,  and  if  a  strong 
50 


786 


THE  FEMALE  GENERATIVE  ORGANS 


caustic  has  been  employed  she  should  be  warned  that  at  first  there  will 
be  an  increased  discharge. 

TAMPONING  THE  UTERUS 

Tamponage  of  the  uterus  may  be  required  to  control  severe  uter- 
ine hemorrhage,  to  secure  dilatation  of  the  cervix  for  the  expulsion  of 
the  uterine  contents  or  in  preparation  for  intrauterine  manipulations, 
and  to  aid  in  the  separation  of  retained  products  of  conception.  The 
technic  of  tamponing  the  uterus  for  the  control  of  hemorrhage  is 


Fig.  821. — Instruments  for  tamponing  the  uterus.      I,   Garrigues'  speculum;  2, 
sponge  holder;  3,    tenaculum;  4,  uterine  dressing  forceps;  5,  uterine  packer. 

something  with  which  every  physician  should  be  familiar,  as  occasions 
may  arise  when  the  operation  is  demanded  without  delay  as  a  life- 
saving  measure;  at  the  same  time  it  should  be  regarded  as  a  surgical 
procedure  and  one  that  should  always  be  performed  under  thorough 
aseptic  precautions.  The  position  and  size  of  the  uterus  should  be 
ascertained  by  bimanual  examination  beforehand,  otherwise  the 
uterus  may  be  injured  in  attempting  to  insert  the  packing. 

Instruments. — A  Simon  or  a  Garrigues  speculum,  sponge  holders, 
two  bullet  forceps,  a  pair  of  uterine  dressing  forceps,  or  a  cannula  and 
packer  are  required  (Fig.  821).  In  the  majority  of  cases  a  pair  of 
curved  dressing  forceps  may  be  employed  for  inserting  the  packing, 
but,  where  the  cervix  is  not  well  dilated,  a  special  packer,  such  as  is 
shown  in  Fig.  822,  by  means  of  which  the  packing  is  pumped  into  the 
uterus  through  the  cannula,  is  more  convenient. 


TAMPONING    THE    UTERUS 


787 


Packing  Material. — The  most  satisfactory  material  to  pack  with 
is  steriHzed  gauze.  This  should  be  folded  into  strips  2  inches  (5  cm.) 
wide  for  use  when  the  cervix  is  well  dilated  and  into  strips  1/2  inch 
(i  cm.)  wide  for  an  incompletely  dilated  cervix.      Care  should  be- 


Fig.  822. — Showing  the  cannula  and  plunger  of  the  uterine  packer  separated. 

taken  to  see  that  the  strips  are  so  folded  that  no  frayed  edges  are 
exposed.  The  gauze  is  best  kept  in  long  strips  packed  in  sterile  glass 
tubes. 

Asepsis. — The  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution.     The  patient's  external  genitals  are  washed  with 


Fig.  823. — Method  of  tamponing  the  uterus  with  a  long  strip  of  gauze  inserted  by 
means  of  dressing  forceps. 

soap  and  water,  followed  by  a  i  to  2000  bichlorid  solution  and  the 
vagina  is  first  cleansed  with  soap  and  water  and  then  douched  with  a 
I  to  5000  solution  of  bichlorid  of  mercury. 

Position  of  Patient. — The  patient  should  be  in  the  hthotomy 
position. 

Preparations  of  Patient. — The  patient's  bladder  and  bowels  should 
be  empty. 


788 


THE  FEMALE  GENERATIVE  ORGANS 


Technic. — Any  clots  are  first  wiped  out  of  the  vagina.  The  cer- 
vix is  exposed  by  means  of  the  speculum  and  the  anterior  and  pos- 
terior lips  are  seized  in  bullet  forceps  which  are  given  to  an  assistant 
to  hold.  A  strip  of  gauze  is  then  seized  in  dressing  forceps  in  such  a 
way  that  the  gauze  falls  over  the  end  of  the  forceps  so  as  to  avoid 
inflicting  any  injury  upon  the  tissues  and  is  carried  to  the  fundus. 
Successive  sections  of  the  gauze  are  inserted  in  the  same  manner  until 
the  cavity  is  filled  (Fig.  823).  Whenever  possible,  a  single  strip  of 
gauze  should  be  employed.     While  inserting  the  gauze  the  operator's 


Fig.  824. — Method  of  using  the  uterine  packer. 

free  hand  should  be  kept  upon  the  abdomen  in  order  to  control  the 
uterus,  and  care  should  be  taken  that  the  gauze  does  not  come  in 
contact  with  anything  that  is  not  sterile.  The  end  or  ends  of  the 
gauze,  if  more  than  one  strip  is  used,  should  be  left  projecting  into 
the  vagina,  so  that  it  may  be  easily  found,  when  the  gauze  is  to  be 
removed,  which  should  be  within  twenty-four  hours  of  its  insertion. 

In  cases  of  severe  hemorrhage  the  vagina  also  should  be  packed 
(see  page  776),  taking  care,  however,  to  tie  the  vaginal  strip  to  that 
within  the  uterus  or  else  to  bring  the  ends  of  both  vaginal  and  uterine 
strips  to  the  vaginal  outlet.  Upon  removal  of  the  gauze  a  vaginal 
douche  should  be  given. 

In  tamponing  the  uterus  by  means  of  the  special  packer  shown  in 
Fig.  822,  the  cervix  is  exposed  as  before  and  is  drawn  down  by  means 
of  bullet  forceps.     The  cannula  is  then  inserted  into  the  uterus  and  a 


PELVIC    MASSAGE  789 

narrow  strip  of  gauze  is  caught  on  the  sharpened  end  of  the  piston  and 
is  carried  into  the  uterus  by  a  pumping  motion  of  the  piston  (Fig, 
824). 

BIER'S  HYPEREMIC  TREATMENT  IN  GYNECOLOGY 

Passive  hyperemia  by  means  of  special  forms  of  suction  cups 
appHed  to  the  cervix  uteri  has  been  employed  with  good  results  in 
cases  of  puerperal  and  other  forms  of  infections  of  the  cervix  and 
uteruSj  in  ulcerations  of  the  cervix,  in  chronic  metritis,  and  in  amenor- 
rhea. The  use  of  cups  is  contraindicated,  however,  if  the  adnexa  are 
inflamed. 

In  dysmenorrhea  there  have  been  numerous  favorable  reports 
from  the  application  of  large  suction  cups  to  the  breast  once  or  twice 
a  day  for  periods  of  fifteen  to  thirty  minutes,  beginning  a  few  days 
before  the  date  of  expected  menstruation  and  continuing  the  treat- 
ments till  the  end.  Pelvic  exudates  have  also  been  treated  with 
success  by  means  of  hot-air  boxes  in  which  the  pelvis  and  hips  rest. 

The  apparatus  for  obtaining  active  and  passive  hyperemia,  as 
well  as  the  method  of  its  use,  have  been  previously  described  in 
Chapter  IX. 

PELVIC  MASSAGE 

Pelvic  massage  after  the  method  of  Brandt  has  been  employed  for 
the  purpose  of  hastening  the  absorption  of  pelvic  exudates  through 
stimulation  of  the  circulation  and  lymph  currents,  to  stretch  or  sepa- 
rate old  adhesions,  to  stimulate  contractions  in  the  uterus,  and  to 
strengthen  and  tone  up  weakened  or  thickened  pelvic  ligaments.  In 
certain  selected  cases  this  method  of  treatment  has  value.  Pelvic 
massage  must  never  he  employed,  however,  in  the  presence  of  acute 
i  ■iflammation  or  with  pus  collections  in  the  tubes  or  pelvis,  so  that  the 
diagnosis  must  be  carefully  made  in  every  case  before  it  can  be  safely 
attempted,  and  then  it  should  only  be  performed  by  the  physician 
himself.     In  individuals  with  erotic  tendencies  it  should  be  avoided. 

Duration  of  Treatments. — The  massage  is  performed  for  about  ten 
minutes  at  a  sitting. 

Frequency. — Treatments  are  given  daily. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  posture. 

Preparations. — The  bladder  and  bowels  should  be  emptied  before- 
hand and  the  clothing  should  be  loosened  from  the  abdomen. 

Technic. — Under  all  aseptic  precautions  two  fingers  of  the  left 
hand  are  introduced  into  the  vagina  and  are  carried  up  to  the  part  to 


790 


THE  FEMALE  GENERATIVE  ORGANS 


be  massaged.     Then,  by  means  of  the  right  hand  placed  on  the  abdo- 
men, at  first  gentle  circular  movements  and  then  deep  pressure  manip- 


FiG.  825. — Showing  the  position  of  the  hands  in  commencing  pelvic  massage. 


Fig.  826. — Instruments  for  scarification  of  the  cervix,      i,  Bivalve  speculum;  2, 
sponge  holder;  3,  tenaculum;  4,  narrow-bladed  bistoury. 

ulations  are  made  over  the  diseased  part  which  at  the  same  time  is 
raised  and  fixed  within  reach  of  the  external  hand  by  the  internal  fin- 


SCARIFICATION    OF   THE    CERVIX 


791 


gers.  The  manipulations  should  be  begun  each  time  over  the  per- 
iphery of  the  diseased  part  and  should  always  be  made  with  the  great- 
est care  and  with  the  absence  of  any  approach  to  roughness. 

When  employed  for  the  purpose  of  gradually  stretching  adhesions 
or  contracted  ligaments,  gentle  intermittent  traction  is  applied  to  the 
uterus  through  the  internal  and  external  hands  in  a  direction  opposite 
to  the  point  of  the  fixation  (Fig.  825).  By  thus  gradually  stretching 
the  adhesions  and  through  the  stimulating  effect  of  the  manipulations 
the  fibrous  tissue  is  gradually  absorbed  and  the  muscular  and  elastic 
tissues  become  regenerated.  Such  manipulations  are  especially  use- 
ful when  used  in  conjunction  with  hot  douches  and  tampons  in  gradu- 
ally replacing  a  uterus  bound  down  by  adhesions. 


SCARIFICATION  OF  THE  CERVIX 

The  withdrawal  of  blood  from  the  cervix  is  a  valuable  therapeutic 
measure  in  cases  of  chronic  congestion  of  the  uterus  and  pelvic  organs. 


Fig. 


Fig.  827. — Method  of  scarifying  the  cervix  by  punctures.     (Ashton.) 
828. — Scarification  of  the  cervix,  showing  the  method  of  making  the  superficial 
incisions.      (Ashton.) 


It  is  also  employed  with  good  results  for  the  rehef  of  the  pain  and  coHc 
of  delayed  menstruation  due  to  pelvic  congestion. 

Instruments. — A  vaginal  speculum,  sponge  holders,  bullet  forceps, 
and  a  narrow-bladed  bistoury  are  required  (Fig.  826). 

Asepsis. — All  aseptic  precautions  should  be  observed.  The 
instruments  are  to  be  boiled  for  five  minutes  in  a  i  per  cent,  soda  solu- 


79^  I'HE  FEMALE  GENERATIVE  ORGANS 

tion.  The  external  genitals  are  cleansed  with  soap  and  water,  fol- 
lowed by  a  I  to  2000  bichlorid  solution,  and  the  vagina  is  douched. 

Position  of  Patient. — The  patient  should  be  in  the  dorsal  posture. 

Technic. — The  cervix  is  exposed  by  the  speculum  and.  after  being 
mopped  off  by  means  of  a  wipe  moistened  in  a  i  to  2000  bichlorid 
solution,  is  seized  by  the  bullet  forceps  and  is  drawn  well  down  toward 
the  vaginal  outlet.  Numerous  punctures  are  then  made  by  means  of 
the  point  of  the  bistoury  to  the  depth  of  1/4  to  1/2  inch  (6  to  12  mm.) 
around  the  circumference  of  the  cervix  (Fig.  827),  or,  instead  of  punc- 
tures, cross  cuts  may  be  employed  (Fig.  828).  In  this  way  from  1/2 
ounce  (15  c.c.)  to  2  ounces  (60  c.c.)  of  blood  may  be  withdrawn.  A 
tampon  of  ichthyol  and  glycerin  or  tannin  and  glycerin  is  then  inserted 
into  the  upper  portion  of  the  vagina,  to  be  removed  within  twelve 
hours. 

PESSARY  THERAPY 

Pessaries  are  employed  for  the  purpose  of  maintaining  a  retrodis- 
placed  or  prolapsed  uterus  in  place  and  to  support  a  cystocele.  In 
the  case  of  a  prolapse  of  the  uterus  or  a  cystocele  a  pessary  is  only  of 
value  as  a  palliative  measure  where  operative  relief  is  refused  or  is 
undesirable  on  account  of  the  age  or  condition  of  the  patient.  In  a 
certain  proportion  of  retrodisplacements,  however,  a  properly  fitted 
pessary  will  in  time  produce  a  cure,  the  most  favorable  cases  being 
those  in  which  the  displacement  is  only  of  short  duration  as,  for 
example,  after  confinement.  The  only  cases  of  displacement  in  which 
pessary  therapy  is  suitable  are  those  where  the  pelvic  floor  has  suffi- 
cient tonicity  to  give  support  to  the  pessary  and  where  the  displace- 
ment is  not  compUcated  by  pelvic  lesions.  Their  use  is  contraindi- 
cated  in  the  presence  of  considerable  enlargement  or  a  prolapse  of  the 
ovary,  hydrosalpinx,  pyosalpinx,  or  new  growths,  and  where  the 
uterus  is  bound  down  by  adhesions.  Some  cases  of  adhesions,  how- 
ever, under  appropriate  treatment  by  medicated  tampons,  hot 
douching,  etc.,  may  be  so  stretched  or  even  be  made  to  disappear  that 
later  a  pessary  may  be  satisfactorily  employed. 

Pessaries  are  not  designed  as  a  means  of  replacing  a  uterus,  but 
simply  to  hold  the  organ  suspended  in  proper  position  after  it  has  been 
replaced.  This  it  does  by  distending  the  vaginal  walls,  and  not 
through  any  force  exerted  by  the  instrument  upon  the  uterus  itself. 
Every  pessary  should  be  fitted  to  the  individual  case,  and  it  is  here 
that  the  experience  of  the  physician  counts  for  much.  When  properly 
fitted,  the  pessary  should  never  cause  any  pain  or  even  make  the  patient 


PESSARY    THERAPY 


793 


conscious  of  its  presence,  and  it  may  be  worn  for  years,  with  certain 
precautions  as  to  cleanliness,  to  be  mentioned  later,  without  harm. 


Fig.  829.— Hodge-Smith  pessary. 
Fig.  830. — Hodge  pessary. 
Fig.  831.— Ring  pessary. 


Fig.  832. — Gehrung's  pessary. 
Fig.  833.— Skene's  pessary. 


Fj^.  834.-CUP  or  ring  (a)  pessary  with  external  support.      (Ashton.) 


On  the  other  hand,  an  ill-fitting  pessary  «^  ,^^^^  ^^P/^^^,  "";"'; 
not  suitable  for  such  treatment  is  distmctly  harmful.  It  should, 
therefore,  always  be  impressed  upon  the  patient  that  if  the  least  pam 


794  THE  FEMALE  GEXERATR'E  ORGANS 

or  an  undue  amount  of  leucorrhea  results  from  the  insertion  of  the 
pessary,,  she  should  report  to  the  physician  immediately,  or  else 
remove  the  pessary  herself. 

Pessaries. — Pessaries  are  made  of  hard  rubber  in  a  great  variety 
of  shapes.  For  retrodisplacements  the  most  commonly  employed  is 
the  Hodge-Smith  (Fig.  829).  If,  however,  the  pelvic  floor  is  relaxed, 
a  Hodge  pessary  (Fig.  830)  is  preferable,  as  its  wide  lower  bar  renders 
it  less  liable  to  slip  out.  These  act  as  levers  in  the  vagina  in  such  a 
way  that  the  force  is  exerted  upon  the  posterior  cul-de-sac  and  the 
uterosacral  ligaments,  so  that  the  cer\'ix  is  pulled  backward  and  the 
uterus  is  thus  tipped  forward. 

Ring  pessaries  (Fig.  831)  are  also  employed  in  retrodisplacements 
where  there  is  not  sufficient  support  for  the  ordinary  pessary.  They 
act  by  so  distending  the  vagina  in  all  directions  that  the  uterus  is 
supported  by  the  lower  vaginal  structures.  The  ring  should  be 
smooth  and  fairly  thick,  at  least  1/4  inch  (6  mm.),  so  as  to  avoid  any 
danger  of  its  eroding  through  the  vaginal  walls.  The  ring  pessary 
is  also  employed  for  retaining  a  prolapsed  uterus  in  place;  but  in 
many  cases  of  prolapse,  the  perineum  is  so  relaxed  that  the  pessary 
immediately  slips  out.  and  some  sort  of  pessary  held  in  place  by  an 
abdominal  support,  such  as  is  shown  in  Fig.  834,  will  be  necessary. 

For  supporting  a  cystocele  Gehrung's  anteversion  pessarj^  (Fig. 
832)  or  Skene's  pessary  (Fig.  St^t,)  is  often  used  with  success. 

As  previously  stated  the  pessary  should  be  fitted  to  each  individual 
case.  The  shape  of  the  pessary  may  be  readily  changed  by  first 
coating  the  instriiment  with  oil  or  vaselin  and  then  softening  it  by  the 
heat  of  an  alcohol  lamp.  When  it  has  been  moulded  to  the  desired 
shape  it  is  hardened  again  by  immersion  in  cold  water.  The  ten- 
dency is  to  employ  too  large  a  pessary,  which  is  dangerous,  as  it  may 
exert  undue  pressure  upon  the  vaginal  wall  and  produce  excoriations, 
or  in  time  even  ulcerate  through.  On  the  other  hand,  if  the  pessary  is 
too  small,  it  will  not  remain  in  place.  The  safest  plan  is  to  measure 
the  vagina  in  each  case  and  shape  the  pessary  accordingly.  The 
depth  of  the  vagina  is  determined  by  carrying  two  fingers  as  high  as 
possible  into  the  posterior  cul-de-sac  and  measuring  the  distance  from 
the  inferior  border  of  the  symphysis,  while  the  width  is  estimated  by 
noting  the  distance  to  which  the  two  fingers  in  the  vagina  may  be 
separated.  About  1/2  inch  (i  cm.)  should  be  deducted  from  the 
former  measurement  for  the  correct  length  of  the  pessary. 

Asepsis. — The  ring  pessary  may  be  sterilized  by  boiling,  but  the 
others,  if  so  treated,  lose  their  shape;  prolonged  immersion  in  some 


PESSARY    THERAPY 


795 


antiseptic  solution,  such  as  i  to  500  bichlorid  of  mercury,  should  be 
employed  instead. 

Position  of  Patient. — For  inserting  the  pessary  the  patient  is  ordi- 


FiG.  835. — First  step  in  replacing  a  retroverted  uterus.      (Ashton.) 

narily  placed  in  the  dorsal  posture,  though  in  some  cases  the  knee- 
chest  position  may  be  used  to  better  advantage. 

Preparations   of  Patient. — The  bladder  and  bowels  should  be 
empty,  and  the  clothing  well  loosened, 


Fig.  836. — Second  step  in  replacing  a  retroverted  uterus.      (Ashton.) 

Technic. — i.  Replacement  of  the  Retroverted  Uterus. — There  are 
two  methods  of  replacement:  (i)  By  bimanual  manipulation,  and 
(2)  with  the  patient  in  the  knee-chest  posture.     The  former  method 

is  usually  effective  if  the  abdominal  walls  are  not  thick  and  rigid  and 


796 


THE  FEMALE  GENERATIVE  ORGANS 


the  vagina  is  sufficiently  roomy.  It  is  performed  as  follows:  Two 
fingers  of  the  left  hand  are  introduced  into  the  vagina  and  are  carried 
up  into  the  posterior  cul-de-sac  where  they  exert  pressure  in  an 


Fig.  837. — Third  step  in  replacing  a  retroverted  uterus.      (Ashton.) 


upward  and  forward  direction  upon  the  body  of  the  uterus  (Fig.  8^s)- 
As  the  uterus  is  thus  elevated,  the  right  hand  is  placed  upon  the 
abdomen,  and  an  attempt  is  made  to  hook  the  fingers  behind  the  fun- 


FiG.  838. — Second  method  of  replacing  a  retroverted  uterus.     First  step. 
(Kelly  and    Noble.) 

dus  (Fig.  836).  The  fundus  is  then  pulled  forward  by  the  fingers  of 
the  external  hand  while  the  internal  fingers  are  shifted  to  the  anterior 
fornix,  where  they  make  backward  pressure  upon  the  cervix  and  the 


PESSARY    THEBAPY 


797 


lower  segment  of  the  uterus  (Fig.  837).  Sometimes,  however,  it  is 
not  possible  to  raise  the  fundus  past  the  promontory  by  this  method. 
In  such  a  case  the  anterior  lip  of  the  cervix  should  be  grasped  in 


Fig.  839. — Second    method    of    replacing    a    retroverted    uterus.     Second    step. 

(Kelly  and  Noble.) 


Fig.  840. — Second  method  of  replacing  a  retroverted  uterus.     Third  step. 
(KeUy  and  Noble.) 

bullet  forceps,  and  the  whole  uterus  is  then  puUed  down  toward  the 
vaginal  outlet  (Fig.  838).  At  the  same  time  the  index-finger  of  the 
left  hand  covered  with  a  glove  is  inserted  into  the  rectum  and  the 


"98 


THE    FEMALE    GENERATR'E    ORGANS 


fundus  is  elevated  past  the  promontory  (Fig.  839).  The  cervix  is 
then  pushed  backward  (Fig.  840),  the  bullet  forceps  are  removed,  and 
reposition  is  completed  bimanually  as  described  above. 

If  these  manipulations  fail,  the  patient  should  be  placed  in  the 
knee-chest  posture  and  the  posterior  vaginal  wall  retracted  by  means 
of  a  Sims  or  Simon  speculum.  This  frequently  results  in  the  uterus 
falling  forward  through  the  effect  of  gravity.  If  it  does  not,  the  cer- 
vix should  be  grasped  with  bullet  forceps  and  pulled  upward  and  out- 
ward toward  the  vaginal  outlet,  while  the  fundus  is  pushed  forward  by 
means  of  a  pair  of  dressing  forceps  armed  with  a  pledget  of  cotton 


Fig.  841. — -Replacement  of  a  posterior  uterine  displacement  in  the  knee-chest 
position.  Showing  the  cervix  drawn  forward  and  the  fundus  swinging  clear  of  the 
promontory.  Illustration  a  shows  the  fundus  pushed  anteriorly  by  direct  pressure. 
(Ashton.) 

carried  up  into  the  posterior  cul-de-sac  (Fig.  841).  The  patient  is 
then  slowly  and  carefully  turned  to  the  dorsal  position,  and  a  bi- 
manual examination  is  made  to  determine  if  the  uterus  is  still  in  posi- 
tion before  a  pessary  is  inserted. 

In  all  manipulations  toward  replacement  of  a  uterus,  the  utmost 
gentleness  should  he  employed.  If  the  patient  is  very  sensitive  or  the 
abdominal  walls  rigid,  it  is  preferable  to  give  a  general  anesthetic 
rather  than  employ  force. 


PESSARY   THERAPY  799 

2.  Introduction  of  Pessaries. — To  insert  the  ordinary  retroversion 
pessary,  the  left  index-finger  is  carried  into  the  vagina  and  the  vaginal 


Fig.  842. — First  step  in  introducing  a  retroversion  pessary. 

wall  is  retracted,  while  with  the  right  hand,  the  pessary  is  introduced 
at  first  obliquely  (Fig.  842),  and  then  turned  so  that  it  lies  transversely 


Fig.  843. — Showing  the  pessary  in  the  vagina  with  the  posterior  bar  in  contact 
with  the  cervix.     (Ashton.) 

in  the  vagina  (Fig.  843).  The  index-finger  of  the  left  hand  is  then 
shifted  so  that  it  lies  under  the  anterior  bar  with  its -tip  resting  upon 
the  posterior  bar  (Fig.  844).     The  posterior  bar  is  then  pressed  down- 


8oo 


THE  FEMALE  GEXERATR'E  ORGANS 


ward  and  backward  until  it  lies  behind  the  cervix  (Fig.  845).  After 
the  pessar>'  has  been  introduced,  the  patient  is  examined  while  in  the 
erect  position  to  see  if  it  fits  properly.     A  properly  fitting  pessary 


Fig.  844. — Second  step  in  introducing  a  retroversion  pessary,  depressing  the 
posterior  bar  and  inserting  it  behind  the  cervix.      (Ashton.) 

Fig.  845. — Showing  the  retroversion  pessary  in  place.     (Ashton.) 


Fig.  846. — First  step  in  introducing  a  ring  pessary. 

should  hold  the  uterus  in  place  and  at  the  same  time  should  not  be 
so  tight  that  the  examining  finger  cannot  be  passed  between  the 
vaginal  walls  and  the  pessary  on  all  sides. 


PESSARY   THERAPY 


8oi 


The  ring  pessary  is  introduced  in  much  the  same  way,  that  is,  the 
left  index-finger  retracts  the  posterior  vaginal  wall  while  with  the 
fingers  of  the  right  hand  the  pessary  is  introduced  obliquely  into  the 
vagina  (Fig.  846).     It  is  then  turned  transversely  and  is  manipulated 


Fig.  847. — Shows  the  ring  pessary  in  place. 


Pig.  848. — Showing  Skene's  pessary  in  place.      (Ashton.) 

by  the  internal  fingers  until  it  hes  in  proper  position  with  its  opening 
surrounding  the  cervix  (Fig.  847). 

Skene's  cystocele  pessary  is  introduced  into  the  vagina  in  the  same 
manner  as  the  retroversion  pessary,  with  the  posterior  bar  lying 
behind  the  cervix,  and  the  broad  anterior  bar  supporting  the  bladder 
(Fig.  848). 

SI 


802 


THE  FEMALE  GENERATIVE  ORGANS 


Gehrung's  cystocele  pessary  is  more  difficult  to  introduce.  The 
following  method  is  employed:  The  pessary  is  placed  upon  a  table  in 
such  a  way  that  it  rests  upon  its  inferior  arch,  with  the  two  curves, 


Fig.  849. — First  step  in  introducing  Gehrung's  pessary. 

right  and  left,  facing  toward  the  operator,  who  then  grasps  the  curve 
L  between  the  thumb  and  forefinger  of  the  right  hand,  and  inserts 
curve  R  into  the  right  side  of  the  vagina  (Fig.  849)  and  then  curve  L 


Fig.  850. — -Gehrung's  pessary  in  position. 

into  the  left  side.  The  pessary  is  then  manipulated  into  such  posi- 
tion, that  the  superior  arch  lies  up  in  front  of  the  uterus,  the  inferior 
arch  under  the  pubic  arch,  and  the  two  curves  R  and  L  on  the  pos- 
terior vaginal  wall  (Fig.  850). 


DILATATION    OF    THE    CERVIX 


803 


After-care. — Within  three  or  four  days  after  introduction  of  the 
pessary,  the  vagina  is  inspected  to  determine  whether  there  is  any 
erosion  from  undue  pressure  of  the  pessary.  The  patient  is  then 
examined  once  every  month  or  six  weeks,  at  which  time  the  pessary  is 
removed  and  well  cleansed  before  re-insertion  and  the  vagina  is 
examined  for  signs  of  ulceration,  which,  if  present,  necessitate  the 
removal  of  the  pessary  and  the  substitution  of  medicated  tampons 
until  healing  has  been  effected.  Once  a  week  and  after  each  men- 
strual period  the  patient  should  take  a  warm  boric  acid  or  soapsuds 
douche  for  cleansing  purposes,  while,  if  there  is  irritation  from  the 
presence  of  the  pessary,  a  daily  douche  should  be  administered.  In 
cases  where  the  displacement  is  accompanied  by  considerable  uterine 
congestion  and  enlargement,  a  hot  vaginal  douche  should  be  given 
night  and  morning  (see  page  771).  In  all  cases  the  physician  should 
impress  upon  the  patient  the  necessity  of  reporting  if  at  any  time  the 
pessary  causes  any  pain  or  discomfort. 


DILATATION  OF  THE  CERVIX 

Dilatation  of  the  cervix,  while  a  small  operation,  is  one  of  con- 
siderable importance,  as  it  forms  a  part  of  many  gynecological  pro- 


FlG. 


4.  5      '         6 

851. — Instruments  for  dilating  the  cervix,  i,  Garrigues'  speculum;  2, 
sponge  holder;  3,  tenaculum;  4,  uterine  sound;  5,  Goodell  dilators;  6,  Fritsch- 
Bozeman  return-flow  irrigator. 


cedures.     Thus  it  may  be  required  as  a  preliminary  to  exploration  of 
the  interior  of  the  uterus,  intrauterine  irrigations  and  applications, 


8o4 


THE  FEMALE  GENERATIVE  ORGANS 


curettage,  and  to  secure  sufficient  dilatation  for  the  extraction  of 
retained  secundines  following  an  incomplete  abortion.  Dilatation 
of  the  cervix  is  also  employed  for  the  cure  of  dysmenorrhea  and  ster- 
ility dependent  upon  cervical  stenosis.  The  operation  should  always 
be  performed  under  all  aseptic  precautions  and  after  the  position  of 
the  uterus  and  the  condition  of  the  appendages  have  been  first  deter- 
mined by  bimanual  examination.  Pelvic  peritonitis,  pelvic  abscess, 
pyosalpinx,  etc.,  are  contraindications  to  dilatation,  unless  the  pro- 
cedure is  to  be  immediately  followed  by  operative  treatment  of  these 
conditions. 

There  are  two  methods  of  performing  dilatation:  (i)  Gradual 
dilatation  by  means  of  sponge,  laminaria,  or  tupelo  tents,  and  (2) 
rapid  dilatation.  The  former  method,  besides  being  painful,  is  no 
longer  looked  upon  with  favor  on  account  of  the  dangers  of  infection 
and  will  not  be  described. 


Fig.  852. — Hegar's  graduated  dilators.     (Bandler.) 


Instruments. — A  self-retaining  speculum,  a  sponge  holder,  two 
bullet  forceps,  a  uterine  sound,  two  pairs  of  Goodell's  dilators  (a 
small  and  a  large  size),  and  a  Fritsch-Bozeman  return-flow  irrigator 
are  required  (Fig.  851).  Some  operators  prefer  to  employ  graduated 
sound  dilators,  such  as  Hanks'  or  Hegar's  (Fig.  852),  in  place  of  the 
glove  stretcher  form  of  dilator,  as  producing  less  laceration  of  the 
cervical  tissue. 

Asepsis. — The  instruments  are  boiled  in  a  i  per  cent,  soda  solution 
for  five  minutes  and  the  operator's  hands  are  thoroughly  cleansed. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy 
posture. 

Anesthesia. — While  the  operation  may  be  performed  under  local 
anesthesia  by  infiltrating  the  cervical  tissue  with  a  0.2  per  cent, 
solution  of  cocain  or  a  i  per  cent,  novocain  solution,  and  inserting  a 
pledget  of  cotton  saturated  with  a  4  per  cent,  solution  of  cocain  into 
the  cervical  canal,  general  anesthesia  will  be  found  preferable  in  the 
majority  of  cases. 


DILATATION    OF    THE    CERVIX 


80  ! 


Preparations  of  Patient.— The  bladder  and  bowels  are  to  be 
empty.  The  hair  is  shaved  or  closely  cut  from  the  labia  and  the 
external  genitals  are  washed  with  soap  and  water  followed  by  a  i  to 
2000  bichlorid  solution.  The  vagina  is  then  washed  with  soap  and 
water  by  the  aid  of  a  swab  on  a  sponge  holder  and  this  is  followed  by  a 
douche  of  i  to  5000  bichlorid. 

Technic. — The  speculum  is  introduced  into  the  vagina  and  the 
anterior  cervical  lip  is  seized  by  bullet  forceps  and  is  drawn  toward 


Fig.  853. — First  step  in  dilatation  of  the  cervix.     The  cervix  exposed  and  drawn 

down  bv  a  tenaculum. 


the  vaginal  orifice  (Fig.  853).  The  cervix  is  then  swabbed  with  a 
I  to  2000  bichlorid  solution.  A  sound  is  next  introduced  for  the  pur- 
pose of  determining  the  direction  of  the  uterine  canal,  and  this  is 
important  in  order  to  avoid  perforating  or  otherwise  injuring  the 
uterus  with  the  dilators  in  case  of  a  retrodisplacement  or  a  sharp  ante- 
flexion. The  small  size  Goodell  dilator  is  then  inserted  into  the  cer- 
vix, carefully  manipulating  it  past  any  obstruction  from  the  internal 
OS,  but  above  all  avoiding  the  use  of  any  force.  With  the  instrument 
through  the  internal  os  the  dilators  are  gradually  expanded,  first  in 
one  direction  and  then,  after  rotation  of  the  instrument,  in  another, 


8o6 


THE  FEMALE  GENERATIVE  ORGANS 


until  a  moderate  amount  of  dilatation  has  been  obtained,  when  the 
large  size  dilator  may  be  substituted.  The  dilatation  is  thus  con- 
tinued, the  operator  being  guided  as  to  the  force  he  may  exert  by  the 
amount  of  resistance  offered  by  the  cervix,  until  the  cervLx  has  been 
sufficiently  stretched  for  the  purposes  of  the  operation. 

At  the  comi)letion  of  the  operation  the  uterus  is  irrigated  through  a 
Fritsch-Bozeman  double-flow  tube.  Following  the  operation  the 
patient  should  remain  in  bed  three  to  four  days  during  which  time  a 


Fig.  854. — Second  step  in  dilatation  of  the  cervix.     Shows  the  method  of  dilating 
by  means  of  Goodell's  dilators. 

daily  vaginal  douche  of  warm  4  per  cent,  boracic  acid  solution  or  ster- 
ile water  is  given. 

Dilatation  by  means  of  the  Hegar  style  of  dilator  is  comparatively 
simple.  The  cervix  is  exposed  and  drawn  down  as  above,  and  then, 
beginning  with  the  small  ones,  successive  larger  sizes  of  the  dilators 
are  inserted  into  the  cervix  (Fig.  855),  lubricating  each  sound  with 
sterile  vaselin  before  its  introduction.  In  using  the  smaller  sized 
sound  great  care  must  be  observed  against  making  a  false  passage  in 
case  any  obstruction  is  offered  by  the  internal   os. 


CURETTAGE  807 

When  dilatation  is  performed  for  sterility  due  to  stenosis,  some 
operators  follow  the  operation  by  introducing  into  the  cervix  a  hard- 
rubber  stem,  such  as  is  shown  in  Fig.  856,  for  the  purpose  of  maintain- 
ing the  dilatation.     The  stem  is  from  22  to  25  French  in  size  and  is 


Fig.  855. — Showing  the  method  of  dilating  the  cervix  by  means  of  the  graduated 

dilators  of  Hegar. 

provided  with  a  groove  upon  its  lateral  wall  for  the  escape  of  dis- 
charges. It  has  this  objection,  however,  that  it  is  liable  to  irritate  the 
cervical  lining. 


Fig.  856.— Intrauterine  stem  pessary.      (Bandler.) 

CURETTAGE 

Curettage,  or  the  scraping  of  the  inner  lining  of  the  uterine  cavity 
may  be  performed  for  the  purpose  of  removing  diseased  mucosa  in 
chronic  endometritis,  for  the  purpose  of  obtaining  tissue  for  subse- 
quent microscopic  examination  in  suspected  cancer  of  the  uterus,  and 
as  a  preliminary  to  repair  of  the  cervix  and  operations  upon  the  uter- 
ine appendages.     In  puerperal  cases  the  operation  is  indicated  for  the 


8o8 


THE  FEMALE  GENERATIVE  ORGANS 


removal  of  pieces  of  decidua  or  placenta  retained  after  labor  or  follow- 
ing incomplete  abortions. 

The  operation  is  contraindicated  in  cancer  of  the  uterus  except  to 
obtain  tissue  for  examination  and  as  a  preliminary  to  a  radical  opera- 
tion and  likewise  in  pelvic  peritonitis,  pyosalpinx,  pelvic  cellulitis, 
ectopic  pregnancy,  etc.,  unless  as  a  preliminary  to  a  laparotomy. 
Curettage  is  dangerous  in  the  presence  of  submucous  fibroids,  as 
sloughing  of  the  growths  may  result  through  injury  from  the  curet.  I  n 
streptococcus  infections  of  the  uterus,  the  operation,  if  performed  at 


Fig.  857. — Instruments  for  curettage,  i,  Garrigues'  weighted  speculum;  2 
sponge  holder;  3,  tenacula;  4,  uterine  sound;  5,  Goodell  dilators;  6,  Fritsch- 
Bozeman  nozzle;  7,  Sims'  curets;  8,  Martin's  curet;  9,  blunt  curet;  10,  placental 
forceps;   ii,  uterine  dressing  forceps. 

all,  should  be  done  with  caution,  as  new  channels  for  infection  are 
opened  up  by  the  curet  and  extension  of  the  process  to  the  deeper 
tissues  is  liable  to  follow. 

A  curettage  should  always  be  performed  under  the  strictest  asep- 
sis and  with  care  and  gentleness,  as  a  false  passage  may  easily  be 
made  through  the  wall  of  the  uterus  with  the  curet  or  dilator;  espe- 
cially is  this  liable  to  happen  in  septic  conditions  and  in  puerperal  cases 
where  the  uterine  wall  is  soft.  The  position  of  the  uterus  and  the 
condition  of  the  adnexa  should  be  ascertained  beforehand  by  means 
of  a  bimanual  examination. 

Instruments. — A  Simon  or  a  Garrigues  self-retaining  speculum, 
sponge  holders,  two  bullet  forceps,  a  uterine  sound,  a  pair  of  large  and 


CURETTAGE 


809 


smal]  Goodell  dilators,  Sims'  curets,  a  Martin  curet,  a  large  blunt 
curet,  placental  forceps,  uterine  dressing  forceps,  and  a  Fritsch- 
Bozeman  return-flow  irrigator  will  be  required  (Fig.  857). 

Asepsis. — All  the  instruments  are  boiled  for  five  minutes  in  a  i  per 
cent,  soda  solution,  and  the  operator's  hands  are  sterilized  as  for  any 
operation. 

Position  of  Patient. — The  patient  should  be  in  the  lithotomy- 
posture. 

Anesthesia. — General  anesthesia  is  necessary. 


Fig.  858. — Dilatation  and  curettage  of  the  uterus.  Illustration  a  shows  the 
endometrium  being  removed  with  Sims'  curet;  illustration  h  shows  the  mucous 
membrane  on  the  fundus  being  removed  with  Martin's  curet.      (Ashton.) 

Preparations  of  Patient. — The  bladder  and  bowels  are  to  be 
empty.  The  hair  is  shaved  or  cut  from  the  labia  and  the  external 
genitals  are  washed  with  soap  and  water  followed  by  a  i  to  2000 
bichlorid  solution.  The  vagina  is  first  thoroughly  scrubbed  with 
soap  and  water  by  means  of  a  swab  on  a  sponge  holder  and  is  then 
thoroughly  douchedwith  a  i  to  5000  bichlorid  of  mercury  solution. 

Technic. — i.  Nonpuerperal  Cases. — The  cervix  is  exposed  by 
means  of  the  speculum  and  the  anterior  or  both  the  anterior  and 
posterior  lips  are  caught  by  means  of  bullet  forceps  and  are  drawn 
well  down  toward  the  vulva.  The  cervix  is  then  wiped  with  a  swab 
soaked  in  a  i  to  2000  bichlorid  solution  and,  after  first  determining 
the  direction  of  the  canal,  the  cervix  is  dilated  in  the  manner  described 


8io 


THE  FEMALE  GENERATIVE  ORGANS 


on  page  805.  The  entire  uterus  is  then  thoroughly  scraped  with  a 
sharp  curet  of  the  largest  size  that  will  pass  through  the  cervix.  This 
should  be  done  in  a  systematic  manner — for  example,  beginning  with 
the  anterior  wall,  the  curet  is  carried  to  the  fundus  and  is  then  with- 
drawn along  the  front  wall  and  out  of  the  uterus  in  one  sweep.  Any 
adherent  tissue  is  wiped  off  the  curet  and  the  instrument  is  reinserted 
and  withdrawn  over  another  section  of  the  anterior  wall.  The  proc- 
ess is  repeated  until  the  entire  anterior  wall  has  been  scraped,  and 
then  the  two  side  walls  and  the  posterior  wall  are  similarly  dealt 


Fig.  859. — Shows  the  uterine  cavity  being  swabbed  out  with  pure  carbolic  acid. 

(Ashton.) 

with.  A  Martin  curet  is  then  substituted  for  the  Sims  instrument 
and  the  fundus  is  well  scraped.  The  cavity  is  then  irrigated  with 
sterile  water  or  normal  salt  solution  by  means  of  the  return-flow 
catheter  in  order  to  remove  any  debris  or  loose  shreds  of  tissue,  and  a 
light  packing  is  inserted  for  a  few  moments  to  dry  the  cavity.  The 
packing  is  then  removed  and  the  uterine  cavity  is  swabbed  with  pure 
carbolic  acid  introduced  by  means  of  a  cotton  swab  on  dressing  forceps 
(Fig.  859).  In  doing  this  care  must  be  taken  not  to  touch  the  vagina 
with  the  carbolic  acid  and  to  remove  any  excess  of  acid  from  the  swab 
before  inserting  it  in  the  cervix.  The  vagina  is  then  cleansed,  the 
bullet  forceps  are  removed  from  the  cervix,  and  a  light  vaginal  tampon 
is  placed  in  contact  with  the  cervix.  The  vulva  is  finally  covered 
with  a  gauze  pad. 

2.  Puerperal  Cases. — Unless  the  cervix  is  already  dilated,  it  should 
be  stretched  sufficiently  to  admit  one  or,  if  possible,  two  fingers.     The 


CURETTAGE 


>II 


operator  then  inserts  the  index-  and  middle-fingers  or,  if  this  is  not 
possible,  the  index-finger  of  the  right  hand  into  the  uterus  and,  while 
counter  pressure  is  made  over  the  fundus  with  the  left  hand,  he  thor- 
oughly explores  the  cavity  and  separates  any  retained  material"  by 
means  of  the  internal  fingers  (Fig.  860).  Large  pieces  of  tissue  thus 
loosened  may  be  then  removed  by  means  of  placental  forceps.  The 
cavity  of  the  uterus  is  then  irrigated  with  normal  salt  solution  or  with 
sterile  water  and  is  lightly  scraped  with  a  large  dull  curet.  In  doing 
this  great  care  and  gentleness  are  necessary  to  avoid  perforating  the 


Fig.  860. — Digital  currettage  of  the  uterus.     (Ashton.) 

Uterus.  Sharp  curets  should  never  he  employed  in  puerperal  cases. 
After  a  final  exploration  with  the  finger  the  cavity  is  again  irrigated 
and  the  operation  is  concluded  by  cleansing  the  vagina  and  covering 
the  vulva  with  a  sterile  gauze  pad  secured  in  place  by  a  T-bandage. 
Only  in  cases  where  the  operation  is  accompanied  by  severe  bleeding 
or  where  it  is  desired  to  introduce  contraction  in  a  flabby  organ  is  it 
necessary  to  pack  the  uterus  (see  page  786) .  If  this  is  done,  the  pack- 
ing should  be  removed  in  twenty-four  hours. 

After-care. — The  vagina  should  be  douched  daily  with  a  i  to  5000 
warm  bichlorid  solution  followed  by  sterile  water  or  normal  salt  so- 
lution. In  cases  of  curettage  for  simple  endometritis  the  patient  may 
be  allowed  out  of  bed  within  a  week,  in  other  cases  the  duration  of 
the  stay  in  bed  will  depend  upon  the  condition  of  the  patient. 


INDEX 


Abdomen,  aspiration  of,  296 
auscxiltation  of,  747 
inspection  of,  464,  518,  742 
local    anesthesia     in    operations   on, 

86 
mensuration  of,  747 
palpation  of,  743 
percussion  of,  745 
Abdominal    inspection  of  bladder,  650 
massage,  568 
palpation  of  bladder,  652 
of  ureters,  701 
Abscess    cavities,    bismuth    paste    for, 

223 
Absorption    power    of    stomach,    Pen- 
zoldt  and  Faber's  test,  483 
test  of,  483 
test  of  bladder,  659 
Accessory  sinuses,  anatomy  of,  307 
.lavage  of,  336 
skiagraphy  of,  325 
Accidents  during  anesthesia  and  their 

treatment,  48 
A.  C.  E.  general  anesthetic  mixture,  33 
Acid  intoxication,  56 
Active  hyperemia,  220 
Acupuncture,  152 

Administration   of    antiserum   in   cere- 
brospinal meningitis,  283,  284 
of  antitetanic  serum,  284 
of  chloroform,  drop  method,  20 

vapor  method,  23 
of  diphtheria  antitoxin,  183 
of  ether,  closed  method,   16 
drop  method,  14 
semiopen  method,  16 
vapor  method,  17 
of  ethyl  chlorid,  32 
of  general  anesthetics,  i 
of  neosalvarsan,  181 
intramuscular,  183 
intravenous,  182 
of  nitrous  oxid,  26 

and  ether,  30 
of  salvarsan,  175 
intravenous,  179 
preparation  of  solution,  178 


Adrenalin  chlorid  and  saline  solution  in 
shock,  136 
as  aid  to  local  anesthesia,  65 

After-effects  of  general  anesthetics,  55 

After-treatment    of    cases    of    general 
anesthesia,  57 

Air,  hot,  active  hyperemia  by,  220 
inflation  of  colon  with,  521,  563 
of  stomach  with,  471,  473 

Air-bag,  Politzer's,  365 

Albarran's  cystoscope,  706 

Albuminous  expectoration  after  aspira- 
tion of  chest,  293 

Albuminuria,  648 

Alcohol  injections  in  tic  douloureux,  194 

AUigator-jawed    forceps,   Kelly's,    667, 

715 
Allis'  ether  inhaler,  10 
Allport's  ear  syringe,  371 
Anachlorhydria,  475 
Anal  canal,  anatomy  of,  515 
Anesthesia,  arterial,  97 
Bier's  venous,  93 
chloroform,  17 

apparatus,  19 
suitable  cases,  19 
ether,  8 

apparatus,  10 

suitable  cases,  9 
ethyl  chlorid,  30 

suitable  cases,  31 
general,  i 

A.C.E.  mixture  for,  33 

accidents  during,  48 

after-efl'ects,  55 

after-treatment  following,  57 

anesthol  for,  33 

asphyxiation  from,  49 

Billroth's  mixture  for,  33 

C.E.  mixture,  33 

cardiac  paralysis  during,  53 

delayed  poisoning  from,  56 

intravenous,  41 

postoperative    paralyses    follow- 
ing, 56 

precautions  in,  i 

preparations  of  patient  for,  i 


813 


>i4 


INDEX 


Anesthesia,  general,  renal  complications 
of,  56 
respirator^'  complications  of,  55 

paralysis  during,  53 
Schleich's  mixture,  33 
stages  of,  6 
Vienna  mixture,  33 
vomiting  after,  55 
Gwathmey's  oil-ether  method,    47 
infiltration,  64,  71 
insufflation,  intratracheal,  36 
intravenous,  general,  41 
intubation,  34 
local,  59 

adrenalin  chlorid  as  aid  to,  65 
advantages  of,  60 
by  endoneural  infiltration,  76 
by  freezing,  69 
by  infiltration,  71 
by  perineural  infiltration,  76 
by  surface  application  of   anes- 
thetic drugs,  70 
conduction  of  operation  under,  68 
disadvantages  of,  60 
drugs  used  for,  64 
ethyl  chlorid  in,  70 
in  abdominal  operations,  86 
in  hernia  operations,  86 
in  operations  on  anus,  89 
on  bladder,  71 
on  eye,  70 
on  face,  79 
on  head,  78 
on  larjmx,  70 
on  lips,  79 

on  lower  extremity,  89 
on  lower  jaw,  79 
on  mouth,  79 
on  neck,  80 
on  nose,  70 
on  penis,  88 
on  rectum  and  anus,  89 
on  scalp,  78 
on  scrotum,  88 
on  thorax,  81 
on  upper  extremity,  82 
on  urethra,  71,  88 
methods  of  producing,  63 
operations    on    inflamed    tissues 

under,  92 
preparation  of  patient,  67 
suitable  cases,  61 
lumbar,  98 
nitrous  oxid,  23 


Anesthesia,  nitrous  oxid  and  ether,  28 
apparatus,  28 
apparatus,  24 
suitable  cases,  23 

oil-ether  colonic,  47 

rectal,  44 

regional,  64 

sacral,  105 

scopolamin-morphin,  48 

spinal,  98 

terminal,  64 

tracheal,  40 

venous,  93 
Anesthetic  mixtures,  33 
Anesthetics,  general  administration  of,  i 

local,  59 
Anesthetist's  supplies,  5 
Anesthol,  33 
Ankle-joint,   exploratory    puncture    of, 

276 
Anterior  crural  nerve,  cocainization  of, 
89 

nares,  304 

rhinoscopy,  312 

tibial  ner\-e,  cocainization  of,  92 
Antiserum,  administration  of,  in  cere- 
brospinal meningitis,  283 
Antitetanic   serum,    administration   of, 

284 
Antitoxic     sera,    lumbar    puncture    as 

means  of  administering,  283 
Antitoxin,    diphtheria,    administration 
of,  183 
after-effects  of,  186 

syringes,  184 
Antrum  of  Highmore,  307 
Anus,  anatomy  of,  515 

dilatation  of,  529 

inspection  of,  518,  526 

local  anesthesia  in  operations  on, 
89 

palpation  of,  527 
Application  of  caustics  to  lar>'nx,  409 
to  riOS2,  332 

intrauterine,  783 

local  to  cer\'ix,  774 
to  vagina,  774 

of  powders  to  vagina,  775 

to  larynx,  409 
Arterial  anesthesia,  97 
Artery  to  vein  transfusion,  121 
Artificial  leech,  167 

respiration,  51 

sera  for  infusion,  137 


INDEX 


815 


Artificial  sera  for  infusion,  Hare's  form- 
ula for,  137 
Locke's  formula  for,  138 
Ringer's  formula  for,  137 
Szumann's  formula  for,  138 
Arytenoid  cartilages,  anatomy  of,  386 
Ascites,  aspiration  of  abdomen  for,  296 
Ashton's    forceps    for   guiding   ureteral 

catheter,  716 
Asphyxiation   during   general    anesthe- 
sia, 49 
Aspirating  bulb.  Boas',  477 

syringes,  259 

trocar,  286 
Aspiration  of  abdomen  in  ascites,  296 

of  bladder,  692 

of  pericardium,  293 

of  peritoneal  cavity,  296 

of  pleura,  285 

of  stomach  contents,  477 

of  tunica  vaginalis,  300 
Aspirator,  bottle,  for  stomach  contents, 

477 

Connell's  heat  vacuum,  288 

Dieulafoy,  287 

Potain,  286,  693 

syphonage,  289 
Atomizer,  Davidson,  331 

De  Vilbiss,  331 

steam,  413 

Whitall  Tatum,  330 
Atropin  as  preliminary  to  general  anes- 
thesia, 3 
Aural  speculum,  Boucheron's,  356 
electric-lighted,  356 
Gruber's  355 
Toynbee's,  356 

stethoscope,  364 
Auricular    nerve,    great,    cocainization 

of,  78 
Auriculotemporal    nerve,   cocainization 

of,  78 
Auscultation  of  abdomen,  747 

of  colon,  520 

of  esophagus,  437 

of  stomach,  470 

of  uterus,  747 
Auscultatory    method    of    determining 

blood-pressure,  116 
Auto-irrigation  of  bladder,  675 
Auto-massage,  570 

cannon  ball  for,  570 
Automatic  scarificator,  159 
Autoscopy,  399 


Bacteriological  examination,  collec- 
tion of  blood  for,  250 
of  discharges  and  secretions  for, 
238 
from  abscess  cavity,  242 
from  eyes,  243 
from     nose    and     accessory- 
sinuses,  243 
from  serous  cavities,  242 
from  urethra,  244 
from  uterus,  244 
from  vagina,  244 
Ballottement  of  kidney,  701 
Bandage,  elastic,  for  passive  hyperemia, 

209 
Bardet's  stomach   electrode,   511 
Beck's  bismuth  paste  for  diagnosis  and 

treatment  of  fistulous  tracts,  223 
Bed,  ether,  58 
Bellocq's  cannula,  345 
Bennett's  ether  inhaler,  11 
gas  and  ether  apparatus,  28 
nitrous  oxid  inhaler,  25 
Bermingham  nasal  douche,  326 
B-eucain,  66 
Bicoude  catheter,  683 
Bierhoff's  cystoscope,  706 

supports  for  legs  in  cystoscopy,  662 
Bier's  active  hyperemia,  220 
cannula,  94 

passive  hyperemia,  203 
by  bands,  209 
by  cups,  215 

in    diseases   of    nose  and    acces- 
sory sinuses,  343 
in  gynecology,  789 
of  head  and  neck,  209,  212 
of  scrotum,  214 
of  shoulder,  209,  213 
of  testicles,  209,  214 
venous  anesthesia,  93 
Billroth's  esophageal  sound,  454 
general  anesthetic  mixture,  33 
Bimanual  palpation  of  bladder,  653 

of  pelvic  organs,  752 
Binnafont     method     of     catheterizing 

Eustachian  tubes,  370 
Bismuth  paste  for  diagnosis  and  treat- 
ment of  fistulous  tracts,  223 
Bivalve  rectal  speculum,  530 

vaginal  speculum,  759 
Bladder,  absorption  test,  659 
anatomy  of,  642 


8i6 


INDEX 


Bladder,  aspiration  of,  692 
auto- irrigation  of,  675 
calculus   in,    Thompson's    searcher 
for,  653 
X-ray  in  detection  of,  671 
capacity  of,  642 

test  of,  657 
catheterization  of,  680 

in  presence  of  prostatic  hyper- 
trophy, 687 
of  stricture,  686 
continuous  catheterization  of,  689 
cystoscopic  examination  of,  in  male, 

659 

female,  catheterization  of,  687 
growths  of,    destruction    by   high 

frequency  currents,  678 
inflammation  of,  after  passage  of 

urethral  sound,  639 
inspection  of,  650 
instillations  for,  676 
irrigation  of,  671 
palpation  of,  651 
papilloma  of,   destruction  by  high 

frequency  currents,  678 
percussion  of,  651 
sound,  Thompson's,  653 
sounding  of,  653 
Blake's  ear  syringe,  371 
Bleeding,  153 
Blocking,  nerve,  76 

Blood,  collection  of,  for  bacteriological 
examination,  250 

for  microscopical  examination,  245 
expectoration  of,  after  aspiration   of 

chest,  293 
in  urine,  648 
serum,  human,  injection  of,  132 

Welch's   apparatus   for   collecting, 

133 

significance  of,  in  vomitus,  463 

smears,  method  of  making,  246 

transfusion  of,  119.     See  also  Trans- 
fusion of  blood. 

washing,  155 
Blood-pressure,  determination  of,  109 

auscultatory  method,  116 

diastolic,  109 

normal,  no 

systolic,  109 

variations  of,  in  disease,  116 
in  health,  no 
Boas'  apparatus  for  esophageal  lavage, 

450 


Boas'  aspirating  bulb,  477 

rectal  electrode,  572 
Bodenhamer's  rectal  irrigator,  549 
Bodine's   formula   for   cocain   and   salt 

solution,  65 
Bottle  aspirator  for  extracting  stomach 

contents,  477 
Boucheron's  ear  speculum,  356 
Bougies  a  boule,  esophageal,  438 
rectal,  538 
urethral,  594 

dilatation  of  esophageal  strictures 

by,  451 
of  rectal  strictures  by,  565 

esophageal,  438,  453 

Eustachian,  378 
medicated,  380 

examination  of  rectum  by,  537 

filiform,  586 

urethral,  585,  586,  631 

Wales',  538,  566 
Boxes,  hot-air,  221 
Brachial  plexus,  cocainization  of,  82 
Braun's  novocain  solutions,  67 
Brenner's  cystoscope,  705 
Brewer's     method     of     transfusion     of 
blood,  127 

transfusion  tubes,  127 
Bronchoscope,  Jackson's,  401 

Killian's  400 
Brown's  cystoscope,  705,  706 
Buerger's  cystoscope,  706 

transfusion  cannula,  122 

Calculi    in    bladder,    Thompson's 
searcher  for,  653 

in  kidneys,  skiagraphy  of,  730 

ureteral,  skiagraphy  of,  730 

X-ray  in  detection  of,  671 
Caliber  of  urethra,  576 
Cannon  ball  fcr  auto-massage,  570 
Cannula,  Bellocq's,  345 

Bier's,  94 

Brewer's  transfusion,  127 

Buerger's  transfusion,  123 

Crile's  transfusion,  122 

Elsberg's  transfusion,  129 

Hahn's  tracheal,  40 

Levin's  transfusion,  128 

Southey's,  161 

Trendelenburg's  tracheal,  40 
Capacity  of  bladder,  642 
test  of,  657 

of  renal  pelvis,  720 


INDEX 


;i7 


Capacity  of  stomach,  462 

Carbonic  acid  gas,  inflation  of  stomach 

with,  471,  473 
Cardiac  massage,  54 

paralysis  during  anesthesia,  53 
Carrel's  method  of  transfusion  of  blood, 

129 
Cartilage,  cricoid,  anatomy  of,  385 

thyroid,  anatomy  of,  385 
Cartilages,  arytenoid,  anatomy,  of  386 
Casper's  cystoscope,  706 
Catheter,  bicoude,  683 
coude,  682 
female,  687 

Gouley's  tunneled,  682 
Guyon's,  682 
Malecot,  690 
Pezzer,  689 
prostatic,  681 
silver  prostatic,  681 
ureteral,  715 
wax-tipped,  707 
whip,  682 
Catheterization,  continuous,  of  bladder, 
689 
of  Eustachian  tubes,  366 

Binnafont  •  or   Kramer    method, 

370 
Lowenberg's  method,  367 
of  female  bladder,  687 
of  male  bladder,  680 

in  presence  of  prostatic  hyper- 
trophy, 687 
of  stricture,  686 
of  ureters,  705 

direct  view  method,  708 
in  female,  714 
indirect  view  method,  711 
Caustics,  applications  of,  to  ear,  375 
to  larynx,  409 
to  nose,  332 
C.  E.  general  anesthetic  mixture,  33 
Cecum,  anatomy  of,  513 
Cerebrospinal  fluid,  normal,  282 
pathological  variations  in,  282 
meningitis,   administration    of    anti- 
serum in,  283,  284 
pressure,  283 
Cervical  plexus,  cocainization  of,  81 
Cervix,  dilatation  of,  803 
local  applications  to,  774 
scarification  of,  791 
Chloroform,    administration     of,    drop 
method,  20 

52 


Chloroform,   administration   of,   vapor 
method,  23 

anesthesia,  17 
apparatus,  19 
suitable  cases,  19 

delayed  poisoning  from,  56 

inhalers,  19 
Chamberlain's   uterine   douche   nozzle, 

780 
Chapin's  urine  collector,  253 
Chetwood's  alternating  cut-off",  612 

tubes,  599 

urethral  irrigating  nozzle,  611 
Chill,  urethral,  638 
Chromic    acid,    method    of    fusing,   on 

probe,  334 
Clamp,  Crile's,  122 

Levin's  transfusion,  128 
Closed  method  of  administering  ether,  1 6 
Clover's  ether  inhaler,  1 1 
Coakley's  transilluminator,  323 
Cocain,  64 

Bodine's  formula  for,  65 

for  sacral  anesthesia,  107 

morphin  preliminary  to,  68 

Schleich's  formula  for,  65 

solutions,  preparation  of,  64 
sterilization  of,  64 
Cocainization  of  anterior  crural  nerve, 
89 
tibial  nerve,  92 

of  auriculotemporal  nerve,  78 

of  brachial  plexus,  82 

of  branches  of  trifacial  nerve,  80 

of  cervical  plexus,  8 1 

of  digital  nerves,  85 

of  external  cutaneous  nerve,  89 

of  frontal  nerve,  78 

of  genitocrural  nerve,  86 

of  great  auricular  nerve,  78 
occipital  nerve,  78 

of  iliohypogastric  nerve,  86 

of  ilioinguinal  nerve,  86 

of  inferior  dental  nerve,  79 

of  infraorbital  nerve,  79 

of  intercostal  nerve,  81 

of  lingual  nerve,  79 

of  lumbar  nerves,  86 

of  median  nerve  at  wrist,  84 
in  arm,  83 

of  mental  ner\^e,  79 

of  musculospiral  nerve,  83 

of  posterior  tibial  nerve,  92 

of  radial  neive,  84 

of  sciatic  nerve,  89 


8i8 


INDEX 


Cocainization  of  small  occipital  nerv^e, 
78 
of  spinal  cord,  98 
of  superior  laryngeal  nerve,  81 
of  supraorbital  nerve,  78 
of  cervical  plexus,  82 
of  temporomalar  nerve,  78 
of  thoracic  nerves,  86 
of  ulnar  nerve  at  wrist,  84 
in  arm,  83 
Cold,    direct    application,    to    urethra, 
622 
local  anesthesia  by,  69 
Collection  and  preservation  of  patholog- 
ical material,  227 
of   blood    for    bacteriological   exami- 
nation, 250 
for  microscopical  examination,  245 
of  discharges  and  secretions  for 
bacteriological       examination, 
238 
from  abscess  cavity,  242 
from  eyes,  243 
from    nose   and   accessory   sinuses, 

243 

from  serous  cavities,  242 
from  urethra,  244 
from  uterus,  244 
from  vagina,  244 
of  feces,  254 

of  gastric  contents,  254,  474 
of  sputum,  252 
of  urine,  252 
Colon,  anatomy  of,  513 

ascending,  anatomy  of,  514 
descending,  anatomy  of,  514 
inflation  of,  563 

for  diagnostic  purposes,  521 
massage  of,  568 
sigmoid,  anatomy  of,  514 
transverse,  anatomy  of,  514 
tube,  543 
Colonic  anesthesia,  oil-ether,  47 
Color  of  urine,  647 
Connell's  aspirator,  288 
Constipation,  electrotherapy  in,  571 
Continuous  catheterization  of  bladder, 
689 
dilatation  of  urethral  strictures,  640 
Coude  catheter,  682 
Cricoid  cartilage,  anatomy  of,  385 
Crile's  clamps,  122 

method     of     intraarterial     infusion, 
145 


Crile's  method  of  intubation  anesthesia, 
34 
of  transfusion  of  blood,  121,  125 

transfusion  cannula,  122 
Croup  kettle,  413 
Crural  nerve,  anterior,  cocainization  of, 

89 
Cryoscopy  of  urine,  728 
Cup  pessary,  793 
Cupped  sound,  619 
Cupping,  162 

dry,  165 

wet,  166 
Cups  for  abstracting  blood,  163 

for  passive  hyperemia,  215 
Curet,  blunt,  808 

Martin's,  808 

Sims',  808 

urethral,  622 
Curettage,  807 
Curves  of  urethra,  576 
Cutaneous   nerve,    external,    cocainiza- 
tion of,  89 
Cystoscope,  Albarran's,  706 

Bierhoff's,  706 

Brenner's,  705 

Brown's,  705,  706    • 

Buerger's,  706 

Casper's,  706 

direct  view,  660 

Eisner's,  705 

indirect  view,  660 

Kelly's  female,  666,  715 

Lewis',  678,  705 

Luys'  open  tube,  668 

McCarthy's,  706 

Nitze's,  660,  706 

Otis',  660 

Schapira's,  660 
Cystoscopic  treatment,  677 
Cystoscopy  in  female,  665 

in  male,  659 

Davidson  atomizer,  331 

Dawbarn's     method     of     intraarterial 

infusion,  146 
Death,     sudden,     after     aspiration     of 

chest,  293 
Deglutition  murmur,  471 
Dench's  vaporizer,  377 
Dental  nerve,  inferior,  cocainization  of, 

79 

Depressor,  vaginal,  760 
De  Vilbiss  atomizer,  331 


INDEX 


819 


Dewitt's  apparatus  for  regulating  flow 

in  proctoclysis,  557 
Diastolic  blood-pressure,  109 
Dieulafoy  aspirator,  287 
Digital  nerves,  cocainization  of,  86 
palpation  of  nasopharynx,  322 
of  pelvic  organs,  750 
of  rectum,  528 
of  uterine  cavity,  766 
Dilatation,     continuous,     of     urethral 
strictures,  640 
of  cervix,  803 

of  esophageal  strictures,  451 
of  rectal  strictures  by  bougie,  565 
of  urethral  strictures,  627,  640 
Dilator,  Goodell's  uterine,  803 
Hanks'  uterine,  804 
Hegar's  uterine,  804 
Kelly's  urethral,  606,  666,  715 
Kollmann's,  630 
Diphtheria     antitoxin,     administration 
of,  183 
after-effects  of,  186 
Direct  applications  to  nose,  332 
laryngoscopy,  396 
tracheo-bronchoscopy,  400 
lower,  400,  406 
upper,  400,  404 
view  cystoscope,  660 

method      of      catheterization      of 
ureters,  708 
Dorsal  position  for  gynecologic  exami- 
nation, 740 
Double  current  catheter,  672 
Douche,  Bermingham's  nasal,  326 
hot-air,  222 
intrauterine,  779 
nasal,  325 
stomach,  499 

Einhorn's,  499 
vaginal,  771 
Drainage  in  edema  of  lower  extremities, 

160 
Drop  method  of  administering  chloro- 
form, 20 
ether,  14 
Drugs      as     preliminary      to      general 

anesthesia,  3 
Drum  membrane,  ariatomy  of,  351 

determination  of  mobility  of,  359 
incision  of,  381 
massage  of,  380 
Dry  cupping,  165 
inhalations,  415 


Duck-bill  rectal  speculum,  531 
Duodenal  feeding,  505 
pump,  Einhorn's,  506 

Ear,  anatomy  of,  348 

application  of  caustics  to,  375 
inspection  of,  354 
instillations  for,  373 
speculum,  Boucheron's,  356 
,     electric-lighted,  356 
Gruber's,  355 
Toynbee's,  356 
syringe,  370 
AUport's,  371 
Blake's,  371 
syringing,  370 
Edelmann's    modification    of    Galton's 

whistle,  361 
Edema,  acupuncture  for,  152 
of  glottis,  scarification  in,  158 
of  lower  extremities,   drainage  in, 
160 
Einhorn's  duodenal  pump,  506 
esophagoscope,  445 
gastrodiaphane,  484 
stomach  bucket,  481 
douche,  499 
electrode,  511 
Elastic  bands  for  passive  hyperemia,  209 
Elbow-joint,   exploratory   puncture  of, 

274 
Electrode,  Boas'  rectal,  572 
Electrotherapy  in  constipation,  571 
in  diseases  of  stomach,  509 
in  tumors  of  bladder,  678 
Elsberg's    method    of    transfusion    of 
blood,  129 
transfusion  cannula,  129 
Eisner's  cystoscope,  705 
Endoneural  infiltration,  76 
Enemata,  541 

nutrient,  560 
Enteroclysis,  546 

with  double  tube,  554 
with  single  tube,  552 
Epiglottis,  anatomy  of,  385 

method   of   drawing   forward  during 
anesthesia,  50 
Epistaxis,  tamponing  nose  for,  343 
Epsom  salts  for  spinal  anesthesia,  99 
Erect  position  for  gynecologic  examina" 

tion,  742 
Esmarch  bandage  for  passive  hyperemia, 
209 


)2C 


INDEX 


Esmarch  mask,  lO 
Esophageal  bougies,  438,  453 
d  boule,  438 
lavage,  449 
sounds,  437 
Billroth's  454 
Schreiber's,  454 
strictures,  dilatation  of,  451 
tube,  Symonds',  457 
Esophagogastroscope,    Hill-Herschell, 

487 
Esophagoscope,  Einhorn's,  445 
Jackson's,  445 
Mikulicz's,  445 
Esophagoscopy,  445 
Esophagus,  anatomy  of,  435 
auscultation  of,  437 
dilatation  of  strictures  of,  451 
intubation  of,  456 
lavage  of,  449 
normal  constrictions  of,  435 
palpation  of,  437 
percussion  of,  437 
skiagraphy  of,  449 
Ether,  administration  of,  closed  method, 
16 
drop  method,  14 
semi-open  method,  16 
vapor  method,  17 
anesthesia,  8 
apparatus,  10 
suitable  cases,  9 
bed,  58 
inhalers,  10 
Ethmoidal  sinuses,  anatomy  of,  308 
Ethyl  chlorid,  administration  of,  32 
anesthesia,  30 
apparatus,  31 
suitable  cases,  31 
as  local  anesthetic,  70 
inhalers,  31 
Eucain  B,  66 
Eustachian  bougies,  378 
medicated,  380 
tubes,  anatomy  of,  352 
catheterization  of,  366 
inflation  of,  by  catheter,  366 
Politzer's  method,  365 
Valsalva's  method,  364 
medication  of,  377 
Ewald-Boas  test  breakfast,  474 
Ewald's  test  of  motor  power  of  stomach, 
482 


Expectoration,    albuminous,    after    as- 
piration of  chest,  293 
of  blood  after  aspiration  of  chest, 

293 
Experimental  polyuria  test  of  functional 

capacity  of  kidneys,  729 
Exploratory  incision  for  inspecting  kid- 
ney, 731 

for  palpating  pelvic  organs,  768 
laparotomy,  493 
punctures,  258 

of  ankle-joint,  276 

of  elbow-joint,  274 

of  hip-joint,  275 

of  joints,  274 

of  kidneys,  273 

of  knee-joint,  275 

of  liver,  269 

of  lung,  264 

of  pericardium,  265 

of  peritoneal  cavity,  268 

of  pleura,  259 

of  shoulder- joint,  374 

of  spinal  canal,  277 

of  spleen,  271 

of  wrist-joint,  275 
Expression  of  stomach  contents.  476 
External  cutaneous    nerve,    cocainiza- 

tion  of,  89 
Extubation,  423 
Extubator,  O'Dwyer's,  417 

Faber  and  Penzoldt's  test  of  absorp- 
tion power  of  stomach,  483 

Fallopian  tubes,  anatomy  of,  737 

False    passage    from    urethral    instru- 
mentation, 639 

Feces,  bacteriological  examination,  541 
chemical  examination,  541 
collection  of,  for  examination,  254 
examination  of,  541 
macroscopical  examination,  541 
microscopical  examination,  541 

Feeding  by  gavage,  502 
duodenal,  505 
intubation  cases,  422 
by  rectum,  560 

Fever,  urethral,  638 

Fifth  nerve,  anatomy  of,  194 

first  division,  injection  of,  197 
injection  of,  for  neuralgia,  194 
second  division,  injection  of,  198 
third  division,  injection  of,  199 


INDEX 


821 


Filariasis,  salvarsan  in,  176 
Filiform  bougies,  esophageal,  454 

urethral,  586,  631 
Finger  palpation  of  rectum,  528 
Fingers,  local  anesthesia  in  operations 

on,  85 
Finger's  ointment,  619 
Fistulous    tracts,     bismuth    paste    for 

diagnosis    and    treatment    of,    223 
Fluid,  cerebrospinal,  normal,  282 

pathological  variations  in,  282 
Fluorescein  in  gastrodiaphany,  485 
Forceps,  Ashton's,  for  guiding  urethral 
catheter,  716 
KeUy's  aUigator-jawed,  667,  715 
placental,  808 
uterine  dressing,  808 
Formalin  sterilizer,  587 
Fraenkel's  tongue  depressor,  311 
Freezing,  local  anesthesia  by,  69 
Fritsch-Bozeman   uterine   douche   noz- 
zle, 780 
Frontal  nerve,  cocainization  of,  78 
sinus,  anatomy  of,  308 
lavage  of,  340 

transillumination  of,  323,  324 
Functional  capacity  of  kidneys,  deter- 
mination of,  725 
b5''  cryoscopy,  728 
experimental  polyuria  test  for, 

729 
indigo-carmin  test  for,  726 
methylene-blue  test  for,  726 
phenolsulphonephthalein    test 

for,  727 
phloridzin  test  for,  726 
urea  test  for,  726 

Galton's  whistle,  360 

Edelmann's  modification,  361 
Garrigues'  speculum,  765 
Gastric  contents,  collection  of,  254 

juice,  composition,  475 
Gastrodiaphane,  Einhorn's,  484 

Lynch's,  484 
Gastrodiaphany,  483 
Gastroscope,  Jackson's,  486 

Mikulicz's,  485 

Rosenheim's,  485 
Gastroscopy,  485 

combined   direct   and   indirect  view, 
492 

direct  view,  488 

Jackson's  technic,  490 


Gavage,  502 
Gehrung's  pessary,  794 
General  anesthesia,  i.     See  also  Anes- 
thesia, general. 
Generative  organs,  female,  anatomy  of, 

735 

Genitocrural    nerve,    cocainization    of, 
86 

Geraghty  and  Rov/ntree's  test  for  func- 
tional capacity  of  kidneys,  727 

Glass  catheter,  female,  687 
test,  three,  580 
two,  580 

GoodeU's  uterine  dilators,  803 
vaginal  speculum,  759 

Gouley's  tunneled  catheter,  682 
sound,  631 

Goyanes'  method  of  arterial  anesthesia, 

97 

Great  auricular  nerve,  cocainization  of, 
78 
occipital  nerve,  cocainization  of,  78 

Gruber's  ear  speculum,  355 

Guyon's  catheter,  683 

Gwathmey's  gas  and  ether  inhaler,  29 
nitrous  oxid  gas  and  oxygen  inhaler, 

26 
oil-ether  colonic  anesthesia,  47 
.vapor  apparatus,  12 

Gynecologic  examinations,  737 
postures,  740 

Gynecology,    Bier's    hyperemic    treat- 
ment in,  789 

Hahn's  tracheal  cannula,  40 

Hand  injections  for  urethra,  607 ' 

Hanks'  uterine  dilators,  804 

Hare's  formula  for  artificial  serum  for 

infusions,  137 
Harris'  segregator,  721 
Hartmann's  tuning-forks,  361 

vaporizer,  377 
HartweU's    method    of    transfusion    of 

blood,  128 
Hays'  pharyngoscope,  317 
Head  lamp,  electric,  311 
Kirstein's,  397 

local    anesthesia    in    operations    on, 

78 

passive  hyperemia  of,  209,  212 
Hearing  tests,  360 
Heart,  massage  of,  54 

paralysis  of,  during  anesthesia,  53 
Heat  vacuum  aspirator,  Connell's,  288 


822 


INDEX 


Hegar's  uterine  dilators,  804 

Hematuria,  648 

Hemolysis,  tests  for,  in   transfusion  of 

blood,  121 
Hemorrhage  after  passage  of  urethral 

sound,  639 
tamponing  nose  for,  343 

uterus  for,  786 

vagina  for,  779 
Hernia,  local  anesthesia  in  operations 

for,  86 
Herschell-Hill  esophagogastroscope,  487 
Hewitt's  nitrous  oxid  gas  inhaler,  25 
Hiatus  sacralis,  105 
High  tracheotomy,  429 
Highmore,  antrum  of,  307 
Hill-Herschell  esophagogastroscope,  487 
Hip-joint,  exploratory  puncture  of,  275 
Hodge  pessary,  794 
Hodge-Smith  pessary,  794 
Honan's     apparatus     for     intravenous 

anesthesia,  42 
Hot  a'r,  active  hyperemia  by,  220 

boxes,  221 

douche,  222 
Houston's  valves,  516 
Hydrocele,  aspiration  and  injection  of, 

300,  301 
Hyperacidity,  476 
Hyperchlorhydria,  475 
Hyperemia,  active,  220 
passive,  203 

by  bands,  209 

by  cups,  215 

in  diseases  of  nose  and  sinuses,  343 

in  gynecology,  789 

of  head  and  neck,  209,  212 

of  scrotum,  214 

of  shoulder,  209,  213 

of  testicles,  209,  214 
Hypoacidity,  476 
Hypochlorhydria,  475 
Hypodermic  injection  of  drugs,  170 

syringes,  170 
Hypodermoclysis,  148 

Iliohypogastric    nerve,    cocainization 

of,  86 
Ilioinguinal  nerve,  cocainization  of,   86 
Illumination  for  rhinoscopy,  310 
Incision,     exploratory,    for    inspecting 
kidney,  731 
for  palpating  pelvic  organs,  768 
of  drum  membrane,  381 


Indigo-carmin    test    of    functional    ca- 
pacity of  kidneys,  726 
Infectious  diseases,  salvarsan  in,  176 
Inferior  dental  nerve,  cocainization  of, 

79 

Infiltration  anesthesia,  64,  71 
endoneural,  76 
perineural,  76 
Infiltrator,  Matas',  72 

Morrow's,  73 
Inflamed  tissues,  operations  on,  under 

local  anesthesia,  92 
Inflation   of   colon   for  diagnostic  pur- 
poses, 521 
in  intussusception,  563 
of  middle  ear,  363,  376 
Politzer's  method,  365 
through  catheter,  366 
Valsalva's  method,  364 
with  medicated  vapors,  376 
of  stomach,  471 
by  air,  471,  473 
by  carbonic  acid  gas,  471,  473 
Infraorbital  nerve,  cocainization  of,  79 
Infusions  of  physiological  salt  solution, 

135 

intraarterial,  144 

intravenous,  138 

rectal,  554 

subcutaneous,  148 
Inhalations,  dry,  415 

steam,  412 
Inhaler,  Allis'  ether,  10 

Bennett's  ether,  13 
gas  and  ether,  29 
nitrous  oxid,  25 

Clover's  ether,  11 

Esmarch  chloroform,  10 

Gwathmey's  gas  and  ether,  29 
nitrous  oxid  gas  and  oxygen,  26 
vapor,  12 

Hewitt's  nitrous  oxid  gas,  25 

Junker's  chloroform,  20 

Schimmelbusch  chloroform,  11,  31 
Injection,  hand,  for  urethra,  607 

of  fluid  or  air  into  bowels  in  intus- 
susception, 563 

hypodermic,  170 

intramuscular,  170 

test  for  urethral  pus,  581 

treatment  of  neuralgia  by,  194 
of  sciatica  by,  200 
of  tic  douloureux  by,  194 
Inspection  of  abdomen,  464,  518,  742 


INDEX 


823 


Inspection  of  anus,  526 

of  bladder,  650 

of  ear,  354 

of  kidneys,  698 

by  exploratory  incision,  731 

of    nasopharynx    by   Hays'   phan,-n- 
goscope,  317 

of  nose,  309 

of  rectum,  518,  526 

of  stomach,  464 

of  urethra  in  female,  581 
in  male,  581 

of  vagina,  748,  759 
Instillation     syringe,   Keyes-Ultzmann, 

616,  677 
Instillations  for  bladder,  676 

for  ear,  373 

for  urethra,  616 
Insufflation    anesthesia ,    intratracheal, 

36 
Insufflations  for  larj^nx,  411 

for  nose,  334 
Insufflator,  laryngeal,  412 

nasal,  334 
Intercostal  nerve,  cocainization  of,   81 
Intestine,  lavage  of,  540 
Intraarterial  infusion  of  salt  solution, 
144 

Crile's  method,  145 

Dawbam's  method,  146 
Intramuscular   administration   of   neo- 
salvarsan,  183 

injections  of  drugs,  170 
Intrastomachic     application     of     elec- 
tricity to  stomach,  511 
Intratracheal  insufflation  anesthesia,  36 
Intrauterine  applications,  783 

douche,  779 
Intravenous   administration   of  neosal- 
varsan,  182 
of  salvarsan,  179 

general  anesthesia,  41 

infusion  of  salt  solution,  138 
Intubation  anesthesia,  34 

of  esophagus,  456 

of  larynx,  415 

tubes,  O'Dw^^er's,  416 
Intubator,  O'Dwyer's,  417 
Intussusception,    injection    of    air   and 

fluids  in,  563 
lodipin  test  of  motor  power  of  stomach, 

482 
Irrigations,  auto-  of  bladder,  675 

bladder,  671 


Irrigations,  rectal,  546 

urethral,  611 

vaginal,  771 
Irrigator,  double  flow  rectal,  548,  549 

Valentine's,  611 
Iversen's  apparatus  for  proctoclysis,  557 

Jackson's  bronchoscope,  401 

esophagoscope,  445 

gastroscope,  486 

laryngoscope,  38,  396 

technic  of  gastroscopy,  490 
Janeway's  sphygmomanometer,  113 
Jaw,  method  of  holding  forward,  during 

anesthesia,  50 
Joints,  exploratory^  puncture  of,  274 
Junker's  chloroform  inhaler,  20 

Kelly's    aUigator-jawed    forceps,  667, 

715 
cone-shaped  urethral  dilator,  606 
female  cystoscope,  666,  715 
method     of     collecting     urine     from 
ureter    without    ureteral    catheter, 
719 
proctoscope,  531 
rectal  specula,  531 
sigmoidoscope,  531 
sphincteroscope,  531 
ureteral  bougie,  715 
catheter,  715 
searcher,  666,  715 
urethral  dilator,  606,  666,  715 

tube-speculum,  605 
urine  evacuator,  666,  715 
Kemp's  double  flow  rectal  irrigator,  548 
Kettle,  croup,  413 
Keyes-Ultzmann    instillation     syringe, 

616,  677 
Kidneys,  anatomy  of,  695 
baUottement  of,  701 
calculus  in,  skiagraphy  of,  730 
exploratory   incision   for   inspecting, 

731 
puncture  of,  273 
functional  capacity  of  determination 
of,    725.      See    also    Functional 
capacity  of  kidneys. 
inspection  of,  698 

by  exploratory  incision,  731 
palpation  of,  699 
pelvic,  capacity  of,  720 

medication  of,  732 
percussion  of,  703 


824 


INDEX 


Kidney,  position  of,  695 

relations  of,  696 

skiagraphj-  of,  730 
Killian's  bronchoscope,  400 

larv'ngoscope,  396 
Kirstein's  head  light,  397 

tongue  depressor,  396 
Klotz's  urethral  tube,  600 
Knee-chest    position     for    gynecologic 
examination,  741 

for  rectal  examination,  525 
Knee-joint,    exploratory'    puncture    of, 

275 

Knife,  urethral,  621 

Kollmann's  dilators,  630 
urethral  syringe,  622 

Kramer's  method  of  catheterizing  Eus- 
tachian tubes,  370 

Kulenkampff's     method     of     blocking 
brachial  plexus,  82 

Lactic  acid  in  stomach  contents,  476 
Laparotomy,  exploratory,  493 
Laryngeal  insiifHator,  412 

nerv'e,  superior,  cocainization  of,  81 

probe,  407 

spray,  408 
Laryngoscope,  Jackson's,  38,  396 

Killian's,  396 
Lar\-ngoscopj-,  389 

direct,  396 
Lary-ngotomy,  428 
Lar^-nx,  anatomy  of,  385 

application  of  caustics  to,  409 

direct  applications  for,  409 

dry  inhalations  for,  415 

insufflations  for,  411 

intubation  of,  415 

palpation  of,  by  probe,  407 

skiagraphy  of,  408 

steam  inhalations  for,  412 
Lavage  of  esophagus,  449 

of  frontal  sinus,  340 

of  intestine,  540 

of  maxillary  sinus,  336 

of  sphenoidal  sinus,  342 

of  stomach,  494 

of  ureters  and  renal  pelvis,  732 
Leech,  artificial,  167 
Leeching,  166 

Length  of  urethra,  estimation  of,  597 
Leube's  test  of  motor  power  of  stomach, 

482 
Levin's  transfusion  clamp,  128 


L^vy  and  Baudouin  needle,  196 
Lewis'  operating  cystoscope,  678 

universal  cystoscope,  705 
Lingual  nerve,  cocainization  of,  79 
Lithotomy  position  in  rectal  examina- 
tion, 525 
Liver,  exploratory  puncture  of,  269 
Local   anesthesia,   59.     See  also  Anes- 
thesia, local. 

applications  to  cer\'ix,  774 
to  vagina,  774 
Locke's  formula  for  artificial  serum  for 

infusions,  138 
Locomotor  ataxia,  salvarsan  in,  176 
Low  tracheotomy,  432 
Lowenberg's    method    of    catheterizing 

Eustachian  tubes,  367 
Lower  direct  tracheo-bronchoscopy,  400, 
406 

extremity,   local   anesthesia  in  opera- 
tions on,  89 
Luer's  hypodermic  syringe,  171 
Lumbar  anesthesia,  98 

ner\-es,  cocainization  of,  86 

puncture,  277 

as  means   of     administering   anti- 
toxic sera,  283 
Lung,  exploratory  puncture  of,  264 
Luys'  open  tube  cystoscope,  668 

segregator,  721 
Lynch's  gastrodiaphane,  484 

Malaria,  salvarsan  in,  176 
Malecot  retention  catheter,  690 
Martin's  curet,  808 
Massage,  abdominal,  568 
auto-,  570 

cannon  ball  for,  570 
colonic,  568 

of  drum  membrane,  380 
of  heart,  54 
of  prostate,  624 
of  stomach,  507 
pelvic,  789 
Matas'  massive  infiltrator,  72 
Maxillary  sinus,  anatomy  of,  307 
lavage  of,  336 

transillumination  of,  323,  325 
McCarthy's  cystoscope,  706 
Meatome,  Otis',  626 
Meatotomy,  626 

Median    nerve,     cocainization     of,     at 
wrist,  84 
in  arm,  83 
Medicated  Eustachian  bougie,  380 


INDEX 


82:: 


Medicated  tampon,  778 

Medication  of  Eustachian  tubes,  377 

of  ureters  and  renal  pelvis,  732 
Meltzer  and  Auer's  method  of    intra- 
tracheal  insufflation   anesthesia,  36 
Membrane,  drum,  anatomy  of,  351 

determination  of  mobility  of,  359 
incision  of,  381 
massage  of,  380 
Meningitis,    cerebrospinal,  administra- 
tion of  antiserum  in,  283,  284 
Mensuration  of  abdomen,  747 
.Mental  nerve,  cocainization  of,  79 
Method   of  inoculating   culture    tubes, 

235 

of  making  smear  culture,  238 

preparation   for  microscopical 
examination,  227 
from  eyes,  230 
from    mouth     and     pharynx, 

229 
from  nose,  230 
from  urethra,  231 
from  uterus,  233 
from  vagina,  233 
stab  culture,  237 
streak  culture,  236 
Methylene-blue  test   of  functional    ca- 
pacity of  kidneys,  726 
Middle  ear,  inflation  of,  376 

with  medicated  vapors,  376 
Mikulicz's  esophagoscope,  445 

gastroscope,  485 
Mirror,  head,  310 
rhinoscopic,  311 
Mixture,  A.  C.  E-,  33 
anesthetic,  33 
anesthol,  33 
Billroth's,  33 
C.  E.,  33 
Schleich's,  33 
Vienna,  33 
Mobility  of  drum  membrane,  determina- 
tion of,  359 
Morgagni's  valves,  516 
Morphin  as  preliminary  to  general  anes- 
thesia, 3 
preliminary  to  cocain,  68 
to  general  anesthesia,  3 
Morrow's  infiltrator,  73 
Motor  functions  of  stomach,  tests  for, 

482 
Murmur,  deglutition,  471 


Murphy's  proctoclysis,   556 

rectal  specula,  532 
Muscular  rheumatism,  acupuncture  in, 

153 
Musculospiral  nerve,   cocainization   of, 

83 
Myles'  nasal  speculum,  311 

Nares,  anterior,  304 
posterior,  304 

digital  palpation  of,  322 
inspection  of,  314 
Nasal  douche,  Bermingham's,  326 
douching,  325 
spraying,  330 
syringing,  329 
Nasopharynx,  digital  palpation  of,  322 
inspection    of,    by    Hays'    pharyngo- 
scope, 317 
Neck,  passive  hyperemia  of,  209,  212 
Neosalvarsan,  administration  of,  181 
intramuscular,  183 
intravenous,  182 
Nerve  blocking,  76 

Neuralgia,  treatment  of,  by  injections, 
194 
trifacial,  treatment  of,  by  injections, 
194 
Neuritis,  acupuncture  in,  153 
Nitrous  oxid,  administration  of,  26 
and  ether,  administration  of,  30 
anesthesia,  28 
apparatus,  28 
anesthesia,  23 
apparatus,  24 
suitable  cases,  23 
inhalers,  24 
and  oxygen  inhaler,  25 
Nitze's  cystoscope,  660,  706 
Nose,  anatomy  of,  304 

application  of  caustics  to,  332 
douching,  325 
inspection  of,  309 
insufflations  for,  334 
passive  hyperemia  in  diseases  of,  343 
probing,  319 
spraying,  33b 
syringing,  329 
tamponing,  343 
Novocain,  67 
.   Braun's  formula  for,  67 
in  sacral  anesthesia,  107 
in  spinal  anesthesia,  99 
Nutrient  enemata,  560 


826 


INDEX 


Obstructive  hyperemia,  203 

by  band,  209 
Occipital    nerve,    great,    cocainization 
of,  78 
small,  cocainization  of,  78 
O'Dwyer's  intubation  instruments,  416 
Odor  of  urine,  646 
Oil-ether  colonic  anesthesia,  47 
Ointment,  application  of,  to  urethra,  618 

Finger's,  619 

syringe,  urethral,  619 

Unna's,  619 
Ossicles  of  ear,  350 
Otis'  cystoscope,  660 

meatome,  626 

urethrometer,  596 
Otoscope,  Siegle's,  359 
Otoscopy,  355 
Ovaries,  anatomy  of,  737 

Palate  retractor.  White's,  311 
Palpation,  digital,  of  nasopharynx,  322 

of  abdomen,  743 

of  anus,  527 

of  bladder,  651 

of  esophagus,  437 

of  kidneys,  699 

of  larynx  by  probe,  407 

of  nose  by  probe,  319 

of  prostate,  584 

of  rectum,  519,  527 
by  finger,  528 
by  whole  hand,  529 

of  seminal  vesicles,  584 

of  stomach,  466 

of  ureters,  701 

of  urethra  in  female,  585 
in  male,  582 

of  uterus,  752 

of  vagina,  750 

of  vulva,  750 
Papilloma  of  bladder,   destruction,   by 

high  frequency  currents,  678 
Paracentesis  of  abdomen,  296 

pericardii,  293 

thoracis,  285 
Paralysis,  cardiac,     during    anesthesia, 

53 

respirator^',  during  general  anesthesia, 

53 
Paresis,  salvarsan  in,  176 
Passive  hyperemia,  203 

by  bands,  209 

by  cups,  215 


Passive  hyperemia  in  diseases  of  nose 
and  accessory  sinuses,  343 
in  gynecology,  789 
of  head  and  neck,  209,  212 
of  scrotum,  214 
of  shoulder,  209,  213 
of  testicles,  209,  214 
Pathological    material,    collection    and 

presen,-ation  of,  227 
Patrick's  formula  for  alcohol  injection 

of  trifacial  nerve,  196 
Pelvic  massage,  789 

organs,  anatomy  of,  735 
bimanual  palpation  of,  752 
digital  palpation  of,  750 
Pelvis,  renal,  capacity  of,  720 

medication  of,  732 
Penis,  local  anesthesia  in  operations  on, 

88 
Penzoldt  and    Faber's   test   of   absorp- 
tion power  of  stomach,  483 
Pepsin  in  gastric  contents,  476 
Percussion  of  abdomen,  745 
of  abdominal  tumors,  746 
of  bladder,  65 1 
of  colon,  520 
of  esophagus,  437 
of  kidneys,  703 
of  stomach,  469 
Percutaneous  application  of  electricity 

to  stomach.  511 
Pericardicentesis,  293 
Pericardium,  aspiration  of,  293 
exploratory  puncture  of,  265 
Perineural  infiltration,  76 
Peritoneal  cavity,  aspiration  of,  296 

exploratory  puncture  of,  268 
Pessary,  794 
cup,  793 
Gehrung's,  794 
Hodge,  794 
Hodge-Smith;  794 
ring,  794 
Skene's,  794 
stem,  807 
therapy,  792 
Pezzer  retention  catheter,  690 
Pharjmgoscope,  Hays',  317 
Pharynx,  inspection  of,  314 
Phenolsulphonephthalein  test  of  func- 
tional capacity  of  kidneys,  727 
Phlebotomy,  153 

Phloridzin   test  of  functional  capacity 
of  kidneys,  726 


INDEX 


827 


Physiological  salt  solution,  infusions  of, 
135 
injection  of,  in  sciatica,  200 
Placental  forceps,  808 
Pleura  aspiration  of,  285 

exploratory  puncture  of,  259 
Pleurocentesis,  285 
Pneumatic  otoscope,  359 

proctoscope,  Tuttle's,  532 
Pneumothorax  after  aspiration  of  chest, 

293 
Poisoning,  delayed  chloroform,  56 
Politzer's  inflation  bag,  365 

method  of  inflating  middle  ear,  365 
Polyuria    test,    experimental,  of    func- 
tional capacity  of  kidneys,  729 
Position,    dorsal,    for    gynecologic    ex- 
amination, 740 

erect,  for  gynecologic  examination, 
742 

for  gynecologic  examinations,  740 

knee-chest,  for  gynecologic  examina- 
tion, 741 

of  kidneys,  695 

Rose's,  for  esophagoscopy,  447 

Sims',  525,  740 

squatting,   for  gynecologic  examina- 
tion, 742 

of  stomach,  461 

of  uterus,  736 
Posterior  nares,  304 

digital  palpation  of,  322 
inspection  of,  314 

rhinoscopy,  314 

tibial  nerve,  cocainization  of,  92 
Potain  aspirator,  286,  693 
Powder   blower,   laryngeal,    412 

nasal,  335 

Sajous',  335 

vaginal,  775 
Powders,  application  of,  to  vagina,  775 
Probe,  rectal,  540 

urethral,  621 
Probing  larynx,  407 

nose,  319 

of  rectum,  539 
Proctoclysis,  continuous,  556 
Proctoscope,  examination  of  rectum  by, 
530 

Kelly's,  531 

Murphy's,  532 

Tuttle's,  532 
Proctoscopy,  534 
Prostate,  anatomy  of,  577 


Prostate,  inflammation    of,   after    pas- 
sage of  urethral  sound,  639 
massage  of,  624 
palpation  of,  584 
Prostatic  catheter,  681 
Psychrophore,  622 
Pump,  Einhorn's  duodenal,  506 
Puncture,  exploratory,  258 

of  ankle-joint,  276 

of  elbow-joint,  274 

of  hip-joint,  275 

of  joints,  274 

of  kidneys,  273 

of  knee-joint,  275 

of  liver,  269 

of  lung,  264 

of  pericardium,  265 

of  peritoneal  cavity,  268 

of  pleura,  259 

of  shoulder-joint,  274 

of  spinal  canal,  277 

of  spleen,  271 

of  wrist-joint,  275 
lumbar,  277 

as    means   of    administering   anti- 
toxic sera,  283 
spinal,  2"] "J 
Pus  in  urine,  649 
Pyelography,  731 
Pyelometry,  720 
Pynchon's  vaporizer,  377 
Pyuria,  649 

QuiNiN  and  urea  hydrochlorid,  67 
for  sacral  anesthesia,  107 

Radial  nerve,  cocainization  of,  84 
Ransohoff's   method    of  arterial    anes- 
thesia, 97 
Reaction  of  urine,  647 
Rectal  anesthesia,  44 
bougie  a  boule,  538 
Wales',  538,  566 
electrode.  Boas',  572 
feeding,  560 

infusion  of  salt  solution,  554 
irrigations,  546 
irrigator,  Bodenhamer's,  549 
Kemp's,  548 
Tuttle's,  549 
palpation  of  ureters,  703 
probe,  540 

speculum,  bivalve,  530 
duck-bill,  531 


828 


IXDEX 


Rectal  speculum,  fenestra ted-blade,  531 
Kelly's,  531 
Murphy's,  532 
Sims',  530 
Tuttle's,  532 
strictures,   dilatation  of,   by  bougie, 

565 

valves,  516 
Recto-abdominal    palpation   of    pelvic 

organs,  757 
Rectum,  anatomy  of,  514 

dilatation  of,  529 

examination  of,  by  bougie   a  boule, 

539 
by  bougies,  537 
by  probe,  539 
by  proctoscope,  530 
by  sounds,  537 
by  speculum,  530 
feeding  by,  560 
inspection  of,  518,  526 
internal  examination,  524 
local  anesthesia  in  operations  on,  89 
palpation  of,  519,  527 
by  finger,  528 
by  whole  hand,  529 
probing  of,  539 
relations  of,  515 
skiagraphy  of,  524 
Regional  anesthesia,  64 
Relapsing  fever,  salvarsan  in,  1 76 
Relations  of  kidneys,  696 
Removal  of  fragments  of  tissue  for  ex- 
amination, 254 
Renal   complications   following  general 

anesthesia,  56 
Rennin  in  gastric  contents,  476 
Replacement  of  retroverted  uterus,   795 
Residual  urine,  estimation  of,  658 

evacuator,  715 
Respiration,  artificial,  51 
Respiratory     complications      following 
general  anesthesia,  55 
parah-sis  during    general  anesthesia, 
53 
Retention  catheter.  690 
Retroverted  uterus,  replacement  of,  795 
Revaccination,  193 
Rhinoscopic  mirror,  311 
Rhinoscopy,  309 
anterior,  312 
posterior,  314 
Riegel  test  dinner,  474 
Ring  pessar>-,  794 


Ringer's  formula  for  artificial  sera,  137 
Rinn^'s  test  for  deafness,  362 
Riva-Rocci  sphygmomanometer,  1 1 1 
Rogers'  sphygmomanometer,  113 
Rood's  apparatus  for  intravenous  anes- 
thesia, 42 
Rosenheim's  gastroscope,  485 
Rose's  posture  for  esophagoscopy,  447 
Rowntree  and  Geraghty's  test  for  func- 
tional capacity  of  kidneys,  ']2'j 

Sacral  anesthesia,  105 
Sajous'  powder  blower,  335 
Saline   solution,   administration  of  ad- 
renalin chlorid  in,  136 

injection  of,  in  sciatica,  200 

intraarterial  infusion,  144 

intravenous  infusion  of,  138 

preparation  of,  136 

rectal  infusion  of,  554 

sterilization  of,  137 

subcutaneous  infusion,  148 
Salvarsan,  administration  of,  175 
intravenous,  179 

preparation  of  solution,  178 
Saxon's  apparatus  for  proctoclysis,  557 
Scarification,  158 

of  cervix,  791 

of  glottis,  158 

of  larynx,  160 

of  tonsil,  159 
Scarificator,  automatic,  159 
Schapira's  cystoscope,  660 
Schimmelbusch  inhaler,  11,  31 
Schleich's  cocain  solutions  for  local  an- 
esthesia, 65 

general  anesthetic  mixture,  33 
Schreiber's  esophageal  sound,  454 
Sciatic  nerve,  cocainization  of,  89 
Sciatica,  injection  of  saline  solution  in, 
200 

treatment  of,  by  injections,  200 
Scopolamin-morphin  anesthesia,  48 
Scrapings  from  uterus,  examination  of, 

768 
Scrotum,  local  anesthesia  in  operations 
on,  88 

passive  hyperemia  of,  214 
Searcher,  Kelly's  ureteral,  666,  715 
Sections  from  uterus,  examination  of, 

768 
Segregation  of  urine,  721 
Harris'  method,  723 
Luys'  method,  725 


INDEX 


829 


Segregator,  Harris',  721 

Luy's,  721 
Seminal  vesicles,  palpation  of,  584 
Semi-open     method    of     administering 

ether,  16 
Serum,  blood,  human,  injection  of,  132 

Welch's  apparatus  for  collecting,  133 
Shock  after  passage  of  urethral  sound, 

638 
Shoulder-joint,     exploratory    puncture 
of,  274 
passive  hyperemia  of,  209,  213 
Siegle's  otoscope,  359 
Sigmoid  colon,  anatomy  of,  514 
Sigmoidoscope,  Kelly's,  531 
Silver  prostatic  cathether,  681 
Sims'  curets,  808 
position,  525,  740 
rectal  speculum,  530 
vaginal  speculum,  760 
Sinus,  ethmoidal,  anatomy  of,  308 
frontal,  anatomy  of,  308 
lavage  of,  340 

transillumination  of,  323,  324 
maxillary,  anatomy  of,  307 
lavage  of,  336 

transillumination  of,  323,  325 
sphenoidal,  anatomy  of,  308 
lavage  of,  342 
Sinuses,  accessory,  anatomy  of,  307 
tubercular,  bismuth  paste  for,  223 
Skene's  pessary,  794 
Skiagraphy  of  accessory  sinuses,  325 
of  colon,  524 
of  esophagus,  449 
of  larynx,  408 
of  renal  calculi,  730 
of  stomach,  493 
of  ureteral  calculi,  730 
of  vesical  calculi,  671 
Small  occipital  nerve,  cocainization  of,  78 
Smal'pox,  vaccination  against,  188 
Smear,  blood,  method  of  making,  246 
culture,  method  of  making,  238 
preparation  for  microscopical  examin- 
ation from  eyes,  230 
from   mouth   and  pharynx, 

229 
from  nose,  230 
from  urethra,  231 
from  uterus,  233 
from  vagina,  233 
method  of  making,  227 
Snare,  urethral,  622 


Sound,  uterine,  765 
Sounding  bladder,  653 
urethra,  585 
uterus,  764 
Sounds,  Billroth's,  454 
bladder,  659 
cupped,  619 
esophageal,  437,  454 
examination  of  rectum  by,  537 
Gouley's,  631 
Schreiber's,  454 
urethral,  585,  586,  629 
Southey's  trocars  and  cannula,  161 
Specific  gravity  of  urine,  646 
Specula,  bladder,  Kelly's,  666 
ear,  Boucheron's,  356 
electric-lighted,  356 
Gruber's,  355 
Toynbee's,  356 
examination  of  rectum  by,  530 
Garrigues',  765 
nasal,  Myles',  311 
rectal,  bivalve,  530 
duck-bill,  531 
fenestrated-blade,  531 
Kelly's,  531 
Murphy's,  532 
Sims',  530 
Tuttle's,  532 
urethral,  620 

Kelly's,  605 
vaginal,  bivalve,  759 
Goodell's,  759 
Sims',  760 
trivalve,  759 
Sphenoidal  sinuses,  anatom}^  of,  308 

'avage  of,  342 
Sphincteroscope,  Kelly's,  531 
Sphygmomanometer,  Janeway's,  113 
Riva-Rocci,  iii 
Rogers',  113 
Stanton's,  113 
Sphygmomsnometry,  109 
Spinal  anesthesia,  98 
canal,  puncture  of,  ^TJ 
cord,  cocainization  of,  98 
Splashing  sounds  in  stomach,  471 
Spleen,  exploratory  puncture  of,  271 
Sponge  holder,  760 
Sprays,  laryngeal,  408 

nasal,  330 
Sputum,  collection  of,  252 
Squatting  position  for  gynecologic  ex- 
amination, 742 


830 


INDEX 


Squatting  position   in    rectal  examina- 
tion, 526 
Stab  cultures,  method  of  making,  237 
Stanton's  sphygmomanometer,  113 
Steam  atomizer,  413 

inhalations,  412 
Stem  pessary,  807 
Steri  ization  of  cocain  solutions,  64 

of  salt  solutions,  137 
Sterilizer,  formalin,  587 
Stethoscope,  aural,  364 
Stockton's  stomach  electrode,  511 
Stomach,    absorption    power    of,    Pen- 
zoldt  and  Faber's  test,  483 
test  of,  483 
anatomy  of,  461 
auscultation  of,  470 
bucket,  Einhorn's,  481 
capacity  of,  462 
contents,  collection  of,  254,  474 
composition  of,  474 
examination,  475 
extraction  of,  474 

aspiration  method,  476 
expression  method,  476 
lactic  acid  in,  476 
pepsin  in,  476 
rennin  in,  476 
douche,  499 

Einhorn's,  499 
electrode,  Bardet's,  511 
Einhorn's,  511 
Stockton's,  511 
Wegele's,  511 
electrotherapy  in  diseases  of,  509 
inflation  of,  471 
by  air,  471,  473 
by  carbonic  acid  gas,  47 1 ,  473 
inspection  of,  464 
lavage  of,  494 
massage  of,  507 

motor  power  of,  Ewald's  test,  482 
iodipin  test,  482 
Leube's  test,  482 
tests  for,  482 
palpation  of,  466 
percussion  of,  469 
position  of,  461 
skiagraphy  of,  493 
splashing  sounds  in,  471 
succussion  sounds  in,  471 
transillumination  of,  483 
tube,  477,  495 
washing  out,  494 


Stomach,  x-ray  examination,  493 
Stools.     See  Feces. 
Stovain  in  spinal  anesthesia,  98 
Streak  culture,  method  of  making,  236 
Strictures  of  esophagus,   dilatation    of, 

451 
of    rectum,     dilatation,     by    bougie, 

565 
of  urethra,  dilatation  of,  627 
continuous,  640 
Subcutaneous  drainage  in  edema,  160 

infusion  of  salt  solution,  148 
Succussion  sounds  in  stomach,  471 
Suction  cups  for  passive  hyperemia,  215 
Sudden  death  after  aspiration  of  chest, 

293 

Superior  laryngeal  nerve,  cocainization 

of,  81 
Supraorbital     nerve,    cocainization    of, 

78 
Swinburne's  urethroscope,  600 
Symonds'  esophageal  tube,  457 
Syphilis,  salvarsan  in,  175 
Syphonage  aspirator,  289 
Syringe,  antitoxin,  184 
aspirating,  259 
for  bismuth  paste  injections,  224 
ear,  370 

hypodermic,  170 
Kollmann's  urethral,  622 
nasal,  329 

urethral,  608,  616,  619 
Systolic  blood-pressure,  109 
Szumann's   formula   for   artificial    sera 
for  infusion,  138 

Talley's    intrauterine  douche    nozzle, 

780 
Tampon,  medicated,  778 

uterine,  786 

vaginal,  776 
Tamponing  nose  for  control  of  hemor- 
rhage, 343 

vagina  for  hemorrhage,  779 
Temporomalar  nerve,  cocainization  of, 

78 
Terminal  anesthesia,  64 
Test,  absorption,  of  bladder,  659 

of    absorption     power    of    stomach, 

483 
of  acuteness  of  hearing,  360 
of  bladder  capacity,  657 
breakfast,  Ewald-Boas,  474 
dinner,  Riegel,  474 


INDEX 


831 


Test,  Ewald's,  of  motor  power  of  stom- 
ach, 482 
experimental  polyuria,  of  functional 

capacity  of  kidneys,  729 
for  hearing,  360 
indigo-carmin,  of  functional  capacity 

of  kidneys,  726 
injection,  for  urethral  pus,  581 
iodipin,  of  motor  power  of  stomach, 

482 
Leube's,  of  motor  power  of  stomach, 

482 
meals,  474 
methylene-blue,  of  functional  capacity 

of  kidneys,  726 
of  motor  power  of  stomach,  482 
Penzoldt    and    Faber's,    for    absorp- 
tion power  of  stomach,  483 
for  perception  of  musical  notes,  362 
phenolsulphonephthalein,     of     func- 
tional capacity  of  kidneys,  727 
phloridzin,  of  functional  capacity  of 

kidneys,  726 
Rinne's,  for  deafness,  362 
Rowntree  and  Geraghty's,  for  func- 
tional capacity  of  kidneys,  727 
three-glass,  for  urethral  pus,  580 
two-glass,  for  urethral  pus,  580 
urea,  of  functional  capacity  of  kid- 
neys, 726 
voice,  of  hearing,  362 
watch,  of  hearing,  360 
Weber's,  for  deafness,  362 
Wolbarst's  three-glass,  580 
Testicles,    passive    hyperemia   of,    209, 

214 
Tetanus   antitoxin,    administration   of, 

284 
Thompson's  stone  searcher,  653 
Thoracentesis,  285 
Thoracic  nerves,  cocainization  of,  86 
Thyroid  cartilage,  anatomy  of,  385 
Tibial  nerve,  anterior,  cocainization  of, 
92 
posterior,  cocainization  of,  92 
Tic  douloureux,   alcohol   injections  in, 
194 
treatment  of,  by  injections,  194 
Tissues,  inflamed,  operations  on,  under 

local  anesthesia,  92 
Tongue  depressor,  Fraenkel's,  311 
Kirstein's,  396 
method  of  drawing  forward,  during 
,   anesthesia,  50 


Towel  cone,  12 
Toynbee's  ear  speculum,  356 
Trachea,  anatomy  of,  387 
Tracheal  anesthesia,  40 
cannula,  Hahn's,  40 
Trendelenburg's,  40 
Tracheo-bronchoscopy,  direct,  400 
lower,  400,  406 
upper,  400,  404 
Tracheoscopy,  389 
Tracheotomy,  424 
high,  429 
low,  432 
tubes,  427 
Transfusion  cannula.  Brewer's,  127 
Buerger's,  123 
Crile's,  122 
Elsberg's,  129 
Levin's,  128 
of  blood,  119 

artery  to  vein,  121 
Brewer's  method,  127 
Carrel's  method,  129 
Crile's  method,  121,  125 
Elsberg's  method,  129 
Hartwell's  method,  128 
selection  of  donor,  121 
tests  for  hemolysis  in,  121 
vein  to  vein,  131 
Transillumination  of  frontal  sinus,  323, 

324 
of  maxillary  sinus,  323,  325 
of  stomach,  483 
Transilluminator,  Coakley's,  323 
Transparency  of  urine,  647 
Trendelenburg  tracheal  cannula,  40 
Trifacial  nerve,  anatomy  of,  194 
branches,  cocainization  of,  80 
first  division,  injection  of,  197 
injection  of,  for  neuralgia,  194 
second  division,  injection  of,  198 
third  division,  injection  of,  199 
neuralgia,  treatment  of,  by  injec- 
tions, 194 
Trivalve  vaginal  speculum,  759 
Trocar    and    cannula     for    aspirating 
bladder,  694 
Southey's,  161 
aspirating,  286 
Tropacocain  in  spinal  anesthesia,  99 
Trousseau  tracheal  dilator,  426 
Tube  for  esophageal  lavage.  Boas',  450 
intubation,  416 
Klotz's  urethral,  600 


832 


INDEX 


Tube,  stomach,  477,  495 

tracheotomy,  427 
Tubercular  sinuses,  bismuth  paste  for, 

223 
Tube-speculum,  Kelly's  urethral,  605 
Tumors    of    bladder,    destruction,    by 

high  frequency  currents,  678 
Tunica  vaginalis,  aspiration  of,  300 
Tuning-forks,  Hartmann's,  361 
Tuttle's  proctoscope,  532 

rectal  irrigator,  549 

Ulnar  nerv-e,  cocainization  of,  at  wrist, 

84 
in  arm,  83 
Unna's  ointment,  619 
Upper      direct     tracheo-bronchoscopy, 
400,  404 
extremity,    local    anesthesia    in    op- 
erations on,  82 
Urea  test  of  functional  capacity  of  kid- 
neys, 726 
Ureteral  bougie,  Kelly's,  715 
calculi,  skiagraphy  of,  730 
catheter,  Kelly's,  715 

wax-tipped,  707 
catheterization,  direct   view   method, 
708 
indirect  view  method,  711 
in  female,  714 
in  male,  705 
searcher,  Kelly's,  666,  715 
stricture,  dilatation  of,  733 
Ureters,  anatomy  of,  697 

catheterization       of,      direct       view 
method,  708  ' 

indirect  view  method,  711 
in  female,  714 
in  male,  705 
medication  of,  732 
palpation  of,  701 
skiagraphy  of,  730 
Urethra,  anatomy  of,  574 
application  of  cold  to,  622 

of  ointments  to,  618 
caliber  of,  576 

collecting   discharges   from,  for  bac- 
teriological examination,  244 
for  microscopical  examination,  231 
curves  of,  576 
estimation  of  length,  597 
examination  of,   by  bougie   a  boule, 

594 

by  sounds  and  bougies,  585 


Urethra,  false  passage  of,  from  instru- 
mentation, 639 

hand  injections  for,  607 

inspection  of,  581 

instillations  for,  616 

irrigations  of,  611 

local  anesthesia  in  operations  on,  88 

palpation  of,  582,  585 

sounding  of,  585 

strictures,  dilatation  of,  627 
continuous,  640 
Urethral  bougie  a  boule,  594 

bougies,  585,  586,  631 

chill,  638 

curet,  622 

dilator,  Kelly's,  606,  666,  715 

fever,  638 

filiforms,  631 

instillations,  616 

irrigating  nozzle,  Chetwood's,  611 

irrigations,  611 

knife,  621 

ointment  syringe,  619 

probe,  621 

snare,  622 

sound,  blunt,  586 
conical,  629 
cupped,  619 
double-taper,  629 

speculum,  620 

strictures,  dilatation  of,  627 
continuous,  640 

syringe,  608 

Kollmann's,  622 

tube,  Klotz's,  600 

tube-speculum,  Kelly's,  605 
Urethritis    after    passage    of    urethral 

sound,  639 
Urethrometer,  596 

Otis',  596 
Urethrometry,  596 
Urethroscope,  599 

in  treatment    of     urethral    diseases, 
620 

Swinburne's,  600 
Urethroscopic  treatment,  620 
Urethroscopy,  in  female,  605 

in  male,  598 
Urinalysis  in  bladder  disease,  646 

in  kidney  disease,  646,  704 
Urine,  albumin  in,  648 

blood  in,  648 

collection  of,  for  examination,  252 
from  infants,  253 


INDEX 


833 


Urine,  collection   of,  in  presence  of  in- 
continence, 253 

collector,  Chapin's,  253 

color  of,  647 

cryoscopy  of,  728 

estimating  quantitj^  of,  for  twenty- 
four  hours,  253 

evacuator,  KeUy's,  666,  715 

examination  of,  646 
in  kidney  diseases,  704 

odor  of,  646 

pus  in,  649 

quantity  of,  passed   in   twenty-four 
hours,  646 

reaction  of,  647 

residual,  estimation  of,  658 

segregation  of,  721 
Harris'  method,  723 
Luys'  method,  725 

specific  gravity,  646 

transparency  of,  647 
Uterine  applications,  783 

dilators,  GoodeU's,  803 
Hanks',  804 
Hegar's,  804 

douche,  779 

nozzle,  Chamberlain's,  780 
Fritsch-Bozeman,  780 
Talley's,  780 

dressing  forceps,  808 

sound,  765 

tampon,  786 
Uterus,  anatomy  of,  735 

applications  to,  783 

collection    of     discharges    from,    for 

bacteriological  examination,  244 

for  microscopical  examination,  233 

curettage  of,  807 

digital  palpation  of,  766 

palpation  of,  752 

position  of,  736 

retroverted,  replacement  of,  795 

scrapings  from,  examination  of,  768 

sections  from,  examination  of,   768 

sounding  of,  764 

tamponing,  786 

Vaccination,  188 
Vagina,  anatomy  of,  735 

application  of  powders  to,  775 
collection  of  discharges  from,   for 
bacteriological  examination,  244 
for  microscopical   examination, 
233 
53 


Vagina,  inspection  of,  748,  759 

local  applications  to,  774 

palpation  of,  750 

relations  of,  735 
Vaginal  depressor,  760 

douche,  771 
nozzle,  771 

inspection  of  bladder,  651 

irrigations,  771 

palpation  of  ureters,  702 

powder  blower,  775 

speculum,  bivalve,  759 
Goodell's,  759 
Sims',  760 
trivalve,  759 

tampon,  776 
medicated,  778 
Vagino-abdominal  palpation  of  pelvic 

organs,  753 
Valentine's  irrigator,  611 
Valsalva's  method   of  inflating   middle 

ear,  364 
Valves,  Houston's,  516 

Morgagni's,  516 

rectal,  516 
Vapor  method  of  administering  chloro- 
form, 23 
ether,  17 
Vaporizer,  Bench's,  377 

Hartmann's,  377. 

Pynchon's,  377 
Vein  to  vein  transfusion,  131 
Venesection,  153 
Venous  anesthesia,  93 

hyperemia,  203 
Vesicles,  seminal,  palpation  of,  584 
Vienna     general     anesthetic     mixture, 

33 
Voice  test  for  hearing,  362 
Vomiting  after  anesthesia,  55 
Vomitus,  blood  in,  463 
Von     Hacker's     method     of     dilating 

esophageal  strictures,  455 
Von  Mikulicz's  esophagoscope,  445 
Vulva,  palpation  of,  750 


Wales'  bougies,  538,  566 
Washing  out  stomach,  494 
Watch  test  for  hearing,  360 
Wax-tipped  ureteral  catheter,  707 
Weber's  test  for  deafness,  362 


834 


INDEX 


Wegele's  stomach  electrode,  511 
Welch's  apparatus  for  collecting  blood 

serum,  133 
Wet  cupping,  166 
Whip  catheter,  682 
Whistle,  Galton's,  360 

Edelmann's  modification,  361 
Whitall  Tatum  atomizer,  330 
White's  palate  retractor,  311 


Wolbarst  three-glass  test,  580 
Wrist-joint,    exploratory    puncture    of, 
275 


X-RAY    examination 
nuses,  325 
of  stomach,  493 


of     accessory    si- 


Yaws,  salvarsan  in,  176 


SAUNDERS'  BOOKS 


on 


Skin,  Genito- Urinary, 

Chemistry,  Eye,  Ear,  Nose, 

and  Throat,  and  Dental 

W.  B.  SAUNDERS   COMPANY 

WEST  WASHINGTON  SQUARE  PHILADELPHIA 

9,  HENRIETTA   STREET,   COVENT  GARDEN,  LONDON 

Davis*   Accessory  Sinuses 

Development  and  Anatomy  of  the  Nasal  Accessory  Sinuses  in 
Man.  By  AVarren  B.  Davis,  M.  D.,  Corinna  Borden  Keen  Research 
Fellow  of  the  Jefferson  3*Iedical  College,  Philadelphia.  Octavo  of  172 
pages,  with  57  original  illustrations.  Cloth,  $3.50  net. 

ORIGINAL  DISSECTIONS 

This  book  is  based  on  the  study  of  two  hundred  and  ninet)'  lateral  nasal  walls, 
presenting  the  anatomy  and  physiology  of  the  nasal  accessor}'  sinuses  from  the 
sixtieth  day  of  fetal  life  to  adva?iced  maturity.  It  represents  the  original  research 
work  and  personal  dissections  of  Dr.  Davis  at  the  Daniel  Baugh  Institute  of 
Anatomy  of  Philadelphia  and  at  the  Friedrichshain  Krankenhaus  of  Berlin.  It 
was  necessary  for  Dr,  Davis  to  develop  a  new  techiiic  by  which  the  accessor)' 
sinus  areas  could  be  removed  en  masse  at  the  time  of  postmortem  examinations, 
and  still  permit  of  reconstruction  of  the  face  without  marked  disfigurement. 
Ninety -six  cases  in  this  series  were  thus  obtained.  The  tables  of  averages,  giving 
you  the  age,  size  of  ostia,  origin,  thickness  of  septum,  and  anterior  and  posterior 
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form  an  extremelv  valuable  feature. 


SAUNDERS'    BOOKS    ON 


Stelwag»onV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Octavo  of  1250  pages,  with  331  text-cuts  and 
33  plates.  Cloth,  $6.00  net;  Half  Morocco,  1^7.50  net. 

THE  NEW  (7th)  EDITION 

There  are  two  features  in  Dr.  Stelwagon's  work  that  stand  out  above  all  the 
others  :  The  special  emphasis  given  the  two  practical  phases  of  the  subject — 
diagnosis  and  treatment;  and  the  wealth  of  illnstratiojis.  These  latter  are  of  real 
value.  They  teach  you  diagnosis  as  no  description  can.  Many  of  these  illustra- 
tions are  in  colors. 

Over  75  pages  of  the  work  are  devoted  to  svphilis,  giving  you  the  Wassermann 
test,  the  salvarsan  ("606")  treatment,  and  all  the  newest  advances.  Pellagra, 
tropical  affections,  hookivorm  disease.  Oriental  sore,  ringworm,  impetigo  contagiosa 
— all  those  diseases  being  so  widely  discussed  to-day. 

George  T.  Elliot,  M.  D.,   Professor  of  Dermatology,  Cornell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judgment, 
for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  derma- 
tology, I  think  it  holds  first  place." 


Schamber£('s  Diseases  qf  the  Skin 
and  E^niptive  Fevers 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  Jay  F.  Schamberg, 
M.  D. ,  Professor  of  Dermatology  and  the  Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.      Octavo  of  585  pages,  illustrated.      Cloth,  ^3.00  net. 

NEW  (3d)  EDITION 

*'  The  acute  eruptive  fevers  constitute  a  valuable  contribution,  the  statements  made 
emanating  from  one  who  has  studied  these  diseases  in  a  practical  and  thorough  manner  from 
the  standpoint  of  cutaneous  medicine.  .  .  .  The  views  expressed  on  all  topics  are  con- 
servative, safe  to  follow,  and  practical,  and  are  well  abreast  of  the  knowledge  of  the  present 
time,  both  as  to  general  and  special  pathology,  etiology,  and  treatment."— American  Journal 
of  Medical  Sciencts. 


GENITO-  URINAR  V  DISEASES 


Norris* 
Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania,  with  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecology,  University  of  Penn- 
sylvania.    Large  octavo  of  5  20  pages,  illustrated.  Cloth,  ^6.00  net. 

A  CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
pubhcations  on  this  subject.  He  has  done  his  work  thoroughly.  He  has  searched 
the  important  literature  very  carefully,  over  2300  references  being  utilized. 
This,  coupled  with  Dr.  Norris'  long  experience,  gives  his  work  the  stamp  of 
authority.  The  chapter  on  serum  and  vaccine  therapy  and  organotherapy  is 
particularly  valuable  because  it  expresses  the  newest  advances.  Every  phase  of 
the  subject  is  considered. 

Pennsylvania  Medical  Journal 

"  Dr.  Norris  has  succeeded  in  presenting  most  comprehensively  the  present  knowledge  of 
gonorrhea  in  women  in  its  many  phases.  The  present  status  of  serum  and  vaccine  therapy  is. 
given  in  detail." 


Braasch's  Pyelog(raphy 

Pyelography.  By  William  F.  Braasch,  M.  D.,  The  Mayo  Clinic, 
Rochester,  Minn.  Octavo  of  323  pages,  with  296  pyelograms.  Cloth, 
$5.00  net. 

A   NEW  WORK 

Dr.  Braasch's  new  work  is  the  first  comprehensive  collection  of  the  various  types  of 
pelvic  outlines,  both  normal  and  pathologic.  You  get  here  296  skiagrams  of  the  renal  pel- 
vis and  ureter,  selected  from  several  thousand  plates  made  at  the  Mayo  Clinic.  These  pye- 
lograms, together  with  the  clear  descriptions,  constitute  an  admirable  aid  to  the  differential 
diagnosis  of  the  various  conditions  affecting  the  renal  pelvis.  The  characteristic  pelvic  out- 
line in  each  disease  is  first  shown  you  by  the  excellent  pyelograms;  then  Dr.  Braasch  inter- 
prets these  pyelograms  for  you  in  diagnostic  terms.  You  get  the  history  of  pyelography,  the 
exact  technic  (selection  of  the  medium,  preparation  of  solution,  method  of  injection,  sources 
of  error,  results),  the  normal  pelves,  the  various  pathologic  outlines,  and  the  outlines  in  con- 
genital anomalies.     It  is  a  most  complete  work. 


SA  UNDERS '     BOOKS    ON 


BarnhiU  an^  Wales* 
Modern  Otology 

A  Text=Book  of  Modern  Otology.  By  John  F.  Barnhill,  M.  D., 
Professor  of  Otology,  Laryngology,  and  Rhinology,  and  Earnest 
DE  W.  Wales,  M.  D.,  Associate  Professor  of  Otology,  Laryngology, 
and  Rhinology,  Indiana  University  School  of  Medicine,  Indianapolis. 
Octavo  of  598  pages,  with  314  original  illustrations.  Cloth,  $5.50  net; 
Half  Morocco,  $7.00  net. 

THE  NEW  (2d)  EDITION 

The  authors,  in  writing  this  work,  kept  ever  in  mind  the  needs  of  the 
physician  engaged  in  general  practice.  It  represents  the  results  of  personal 
experience  as  practitioners  and  teachers,  influenced  by  the  instruction  given  by 
such  authorities  as  Sheppard,  Dundas  Grant,  Percy  Jakins,  Jansen,  and  Alt. 
Much  space  is  devoted  to  prophylaxis,  diagnosis,  and  treatment,  both  inedical 
and  surgical.  There  is  a  special  chapter  on  the  bacteriology  of  ear  affections — 
a  feature  not  to  be  found  in  any  other  work  on  otology.  Great  pains  have  been 
taken  with  the  illustrations,  in  order  to  have  them  as  practical  and  as  helpful  as 
possible,  and  at  the  same  time  highly  artistic.  A  large  number  represent  the 
best  work  of  Mr.  H.  F.  Aitken. 


Coolidg(e  on  Nose  and  Throat 

Manual  of  Diseases  of  the  Nose  and  Throat.  By  Algernon  Cool- 
IDGE,  M.  D.,  Professor  of  Laryngology,  Harvard  Medical  School. 
Octavo  of  360  pages,  illustrated.     Cloth,  ;^i.50  net. 

This  new  book  furnishes  the  student  and  practitioner  a  guide  and  ready  reference  to  the 
important  details  of  examination,  diagnosis,  and  treatment.  Established  facts  are  empha- 
sized and  unproved  statements  avoided.  Anatomy  and  physiology  of  the  different  regions 
are  included. 

Frank  Allport.  M.D. 

Professor  of  Otology,  Northwestern  University,  Chicago. 

"  I  regard  it  as  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  are  especially  good,  particularly  as  they  are  practically  all  original  and  not  the  old 
reproduced  pictures  so  frequently  seen." 


DISEASES   OF   THE  EYE. 


DeSchweinitz's 
Diseases  of  the  Eye 

Just  Out— New  (8th)  Edition 


Diseases  of  the  Eye:  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  deSchweinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Uni- 
versity of  Pennsylvania,  Philadelphia,  etc.  Handsome  octavo  of  754 
pages,  386  text-illustrations,  and  7  chromo-lithographic  plates.  Cloth, 
|6.oo  net;  Sheep  or  Half  Morocco,  $7.50  net. 

THE  STANDARD  AUTHORITY 

The  new  matter  added  includes:  Walker's  testing  of  visual  field,  squirrel 
plague  conjunctivitis,  swimming  bath  conjunctivitis,  anaphylactic  keratitis,  family- 
cerebral  degeneration  with  macular  changes,  ocular  symptoms  of  pituitary 
disease,  sclerectomy  with  a  punch,  preliminary  capsulotomy,  iridotasis,  thread 
drainage  of  anterior  chamber,  extraction  of  cataract  in  capsule  after  subluxation 
of  lens  with  capsule  forceps,  capsulomuscular  advancement  with  partial  resection, 
tenotomy  of  inferior  oblique,  window  resection  of  nasal  duct. 


Bass  and  Johns'   Alveolodental   Pyorrhea 

Alveolodental  Pyorrhea.  By  Charles  C.  Bass,  M.  D.,  Professor 
of  Experimental  Medicine,  and  Foster  M.  Johns,  M.  D.,  Instructor  in 
the  Laboratories  of  Clinical  Medicine,  Tulane  Medical  College.  Octavo 
of  168  pages,  illustrated.  Cloth,  ^2.50  net. 

Drs.  Bass  and  Johns  present  their  subject  from  the  viewpoint  of  infection  by 
the  Endamoeba  buccaUs.  You  get  a  full  account  of  the  Endamoeba  buccalis,  the 
history  of  disease,  the  morbid  processes,  contagiousness,  symptomatology,  how 
to  make  your  diagnosis  from  the  history  and  microscopic  examination,  prophy- 
laxis, and  the  exact  technic  for  using  emetin  hydrochlorid.  You  get  the  action 
of  emetin  upon  the  Endamoeba,  you  get  the  exact  dosage,  you  get  the  interval 
between  doses,  the  local  effect,  the  urticaria  produced,  the  technic  of  injection. 

University  of  Pennsylvania  Medical  Bulletin 

"Upon  reading  through  the  contents  of  this  book  we  are  impressed  by  tne  remarkable 
fulness  with  which  it  reflects  the  notable  contributions  recently  made  to  ophthalmic  literature. 
No  important  subject  within  its  province  has  been  neglected." 


SAUNDERS'  BOOKS   ON 


GET  A ^  •   ^  *.   •*  "^"^  ^^^ 

THE    BEST  ^m***^riCC^n  STANDARD 


American 
Illustrated   Dictionary 

New  (8th)  Edition— 1500  New  Terms 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  100  new  and  elaborate  tables  and  many  illustra- 
tions. By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The  American 
Pocket  Medical  Dictionary."  Large  octavo,  with  1 137  pages,  bound  in 
full  flexible  leather.     Price,  $4.^0  net;  with  thumb  index,  ;^5.oo  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

This  dictionary  is  the  "new  standard."  It  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  terms  are  hve, 
active  words,  taken  right  from  modern  medical  hterature. 

Howard  A.  Kelly.  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore 

"  Dr.  Dorland's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
sije.     No  errors  have  been  found  in  my  use  of  it." 


Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  550pages,  with  219  text-cuts  and  several  colored 
plates.     Cloth,  ^4.50  net ;  Half  Morocco,  ;^6.oo  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensibly  for  the  general  practitioner,  are  in  reality  adapted  only  to  the  specialist  ; 
but  Dr.  Theobald  in  his  book  has  described  ver}'  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  within  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner. 

Charles  A.  Oliver,  M.D., 

Clinical  Professor  of  Ophthalmology,   Woman  s  Medical  College  of  Pennsylvania. 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  the  general  physician  and  medical 
student,  for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.  Mosi 
surely  Dr.  Theobald  has  accomplished  his  purpose." 


DISEASES   OF   THE  EYE. 


Haab  and  DeSchweinitz's 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
1 01  colored  illustrations  on  46  lithographic  plates  and  244  pages  of 
text.     Cloth,  $3.00  net.     In  Saunders'  Hand-Atlas  Series. 

THE  NEW   ;3d)    EDITION 

Conditions  attending  diseases  of  the  external  eye,  which  are  often  socoiHplicated. 
have  probably  never  been  more  clearly  and  comprehensively  expounded  than  in 
the  forelying  work,  in  which  the  pictorial  most  happily  supplements  the  verbal 
description.     The  price  of  the  book  is  remarkably  low. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 

Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Zijrich.  Edited,  with  additions,  by 
G.  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  ^3.00  net.     In  Satmders'  Hand- Atlas  Series. 

THE  NEW   (2d)    EDITION 

The  great  value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  English 
translation.  Not  only  is  the  student  made  acquainted  with  carefully  prepared 
ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the  most  im- 
portant fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic  lesions 
are  added.     The  whole  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet,  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
every  hospital  into  which  ophthalmic  cases  are  received." 


SAUNDERS'  BOOKS  ON 


Cradle's 
Nose,  Pharynx,  and  Ear 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Gradle, 
M.D,,  late  Professor  of  Ophthalmology  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Octavo  of  547  pages,  illustrated, 
including  two  full-page  plates  in  colors.     Cloth,  ^^3.50  net. 

INCLUDING  TOPOGRAPHIC  ANATOMY 

This  volume  presents  diseases  of  the  Nose,  Pharynx,  and  Ear  as  the  author 
has  seen  them  during  an  experience  of  nearly  twenty-five  years.  In  it  are 
answered  in  detail  those  questions  regarding  the  course  and  outcome  of  diseases 
which  cause  the  less  experienced  observer  the  most  anxiety  in  an  individual  case. 
Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  MediczJ  Journal 

"This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  confusion 
incident  to  a  categorical  statement  of  everybody's  opinion." 

Kyle's 
Diseases  of  Nose  and  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  825  pages;  with  2^3  illustrations,  28  in  colors. 
Cloth,  $4.50  net;  Half  Morocco,  ^6.00  net. 

THE  NEW  (5th)  EDITION 

The  new  {sth)  edition  of  Dr.  Kyle's  work  shows  an  increase  of  100  pages  zxi^ 
some  40  new  illustrations.  The  following  new  articles  have  been  added  :  vaccine 
therapy  ;  lactic  bacteriotherapy ;  salvarsan  in  the  treatment  of  syphilis  of  the  upper 
respiratory  tract  ;  sphenopalatine  ganglia  neuralgia  ;  negative  air-pressure  in  ac- 
cessory sinus  disease  ;  chronic  hyperplastic  ethmoiditis  ;  and  congenital  insuffi- 
ciency of  the  palate.  The  tables  of  differential  diagnosis  and  the  prescriptions  are 
striking  points  of  Dr.  Kyle's  book. 

Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book." 


URINE  AND   IMPOTENCE. 


Og'den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.     A  Clinical 

Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  ^3.00  net. 

THE  NEW  (3d)  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  life  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinar)-  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
sp  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Pilcher*s 
Practical  Cystoscopy 

Practical  Cystoscopy.  By  Paul  M.  Pilcher,  M.  D.,  Consulting 
Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of  504  pages, 
with  299  illustrations,  29  in  colors.     Cloth,  $6.00  net. 

NEW  (2d)  EDITION 

Cystoscopy  is  to-day  the  most  practical  manner  of  diagnosing  and  treating 
diseases  of  the  bladder,  ureters,  kidneys,  and  prostate.  To  be  properly  equipped, 
therefore,  you  must  have  at  your  instant  command  the  information  this  book  gives 
you.  It  explains  away  all  difficulty,  telling  you  ivhy  you  do  not  see  something 
when  something  is  there  to  see,  and  telling  you  how  to  see  it.  All  theor)-  has 
been  uncompromisingly  eliminated,  devoting  ever>'  line  to  practical,  needed- 
every-day  facts,  telUng'you  how  and  when  to  use  the  cystoscope  and  catheter- 
telling  you  in  a  way  to  make  you  know.  The  work  is  complete  in  ever)'  detail. 
Bransford  Lewu,  M.  D.,  St.  Louis  University. 

"  I  am  very  much  pleased  with  Dr.  Pilcher's  '  Practical  Cystoscopy.'  I  think  it  is  the  best 
in  the  English  language  now." — April  27,  igii. 


SAUNDERS'   BOOKS    ON 


Goepp's 
Dental  State  Boards 

Dental  State  Board  Questions  and  Answers — By  R.  Max  Goepp, 
M.  D.,  author  "  Medical  State  Board  Questions  and  Answers."  Octavo 
of  428  pages.     Cloth,  ^2.75  net. 

NEW  (2d)   EDITION 

This  new  work  is  along  the  same  practical  lines  as  Dr.  Goepp's  successful  work 
on  Medical  State  Boards.  The  questions  included  have  been  gathered  from  reliable 
sources,  and  embrace  all  those  likely  to  be  asked  in  any  State  Board  examination 
in  any  State.  They  have  been  arranged  and  classified  in  a  way  that  makes  for  a 
rapid  resume  of  every  branch  of  dental  practice,  and  the  answers  are  couched  in 
language  unusually  explicit — concise,  definite,  accurate. 

The  practicing  dentist,  also,  will  find  here  a  work  of  great  value — a  work 
covering  the  entire  range  of  dentistry  and  extremely  well  adapted  for  quick 
reference. 

Haab  and  deSchweinitz's 
Operative  Ophthalmology 

Atlas  and  Epitome  of   Operative    Ophthalmology.       By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology  in  the  University  of  Pennsylvania. 
With  30  colored  lithographic  plates,  1 54  text-cuts,  and  375  pages  of 
text     In  Saiindcrs  Hand- Atlas  Series.     Cloth,  $3.50  net. 


Dr.  Haab's  Atlas  of  Operative  Ophthalmology  will  be  found  as  beautiful  and 
as  practical  as  his  two  former  atlases.  The  work  represents  the  author' s  thirty 
years'  experience  in  eye  work.  The  various  operative  interventions  are  described 
with  all  the  precision  and  clearness  that  such  an  experience  brings.  Recognizing 
the  fact  that  mere  verbal  descriptions  are  frequently  insufficient  to  give  a  clear 
idea  of  operative  procedures.  Dr.  Haab  has  taken  particular  care  to  illustrate 
plainly  the  different  parts  of  the  operations. 

Johns  Hopkins  Hospital  Bulletin 

"  The  descriptions  of  the  various  operations  are  so  clear  and  full  that  the  volume  can  well 
hold  place  with  more  pretentious  text-books." 


GENITO- URINARY   AND    NOSE,     THROAT,     ETC. 


Greene  and  Brooks* 
Genito-Urinary  Diseases 

Diseases  of    the   Genito=Urinary  Organs  and  the  Kidney.      By 

Robert  H.  Greene,  M.  D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medical 
School.  Octavo  of  639  pages,  illustrated.  Cloth,  ^5.00  netj  Half 
Morocco,  ^^6.50  net. 

THE  NEW   (3d)  EDITION 

This  new  work  presents  both  the  medical  and  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

"As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinary 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of   Diseases  of   the    Nose,  Throat,  and    Ear.     By  E. 

Baldwin  Gleason,  M.  D.,  LL.  D.,  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia.  i2mo  of  590  pages,  profusely  illus- 
trated.    Cloth,  ^2.50  net. 

THE  NEW  (3d)  EDITION 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  are  few 
books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Genito=Urinary  Diseases,  Syphilis,  and 
Diseases  of  the  Skin.  Edited  by  L.  Bolton  Bangs,  M.  D..  and 
W.  A.  Hardaway,  M.  D.  Octavo,  1229  pages,  300  engravings,  20 
colored  plates.     Cloth,  ;^7.oo  net. 


SAUNDERS'  BOOKS  OX 


Holland's  Medical 
Chemistry  and  Toxicology 

A  Text-Book  of  Medical  Chemistry  and  Toxicology.  By  James 
W.  Holland,  M.  D.,  Emeritus  Professor  of  Medical  Chemistry  and 
Toxicology,  and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  678  pages,  fully  illustrated.     Cloth,  $3.CX)  net. 

FOURTH  EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years' 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistr)-  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.      More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry'. 

American  Medicine 

"  Its  statements  are  clear  and  terse  ;  its  illustrations  well  chosen  ;  its  development  logical, 
systematic,  and  comparatively  easy  to  foliow.  .  .  .  We  heartily  commend  the  work." 

Ivy's  Applied  Anatomy  and 

Oral  Surgery  for  Dental  Students 


Applied   Anatomy  and   Oral   Surgery  for  Dental  Students.    By 

Robert  H.  Ivy,  M.D.,  D.D.S.,  Assistant  Oral  Surgeon  to  the  Philadel- 
phia General  Hospital.     i2mo  of  280  pages,  illustrated.     Cloth,  $1.50 

net. 

FOR  DENTAL  STUDENTS 

This  work  is  just  what  dental  students  have  long  wanted — a  concise,  practical 
work  on  applied  anatomy  and  oral  surgery,  written  with  their  needs  solely  in 
mind.  No  one  could  be  better  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate 
in  both  dentistry  and  medicine.  Having  gone  through  the  dental  school,  he 
knows  precisely  the  dental  student's  needs  and  just  how  to  meet  them.  His 
medical  training  assures  you  that  his  anatomy  is  accurate  and  his  technic  modern. 
The  text  is  well  illustrated  with  pictures  that  you  will  find  extremely  helpful. 

H.  P.  Kuhn,  M.D.,  Western  Dental  College,  Kansas  City. 

"  I  am  delighted  with  this  compact  little  treatise.     It  seems  to  me  just  to  fill  the  bill." 


CHEMISTRY,   SKIN,  AND   VENEREAL   DISEASES.  13 


American  Pocket  Dictionary  New  rgth)  Edition 

The  American  Pocket  Medical  Dictionary.    Edited  by  W.  A. 

Newman  Borland,  M.  D.,  Editor  "  American  Illustrated  Medical 

Dictionary."     Containing  the  pronunciation  and  definition  of  the 

principal  words  used  in  medicine  and  kindred  sciences.    693   pages. 

Flexible  leather,  with  gold  edges,  ;^i.oo  net;  with  thumb  index, 

$1.21  net. 

James  W.  Holland,  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College 
Philadelphia,  ' 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  ] 
can  recommend  it  to  our  students  without  reserve." 

Stelwagon*s  Essentials  of  Skin  7th  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D.,  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  291  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  ;^i.oo  net.  In 
Saunders'  Question- Compend  Series. 
The  Medical  News 

"  In  line  with  our  present  Icnowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been  noted." 

Wolffs  Medical  Chemistry  New  (7th)  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Witmer,  Ph.  G.,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  ^i.oo  net.  In 
Saunders'  Question- Compend  Series. 

Bliss*  Qualitative  Chemical  Analysis 

Qualitative  Chemical  Analysis.  By  A.  R.  Bliss,  Jr.,  Ph.  G., 
M.  D.,  Professor  of  Chemistry  and  Pharmacy,  Birmingham 
Medical  College,  Alabama.  Octavo  of  250  pages.  Cloth,  32.00 
net. 

Vecki*s  Sexual  Impotence  New  (sth)  Edition 

Sexual  Impotence.  By  Victor  G.  Vecki,  M.  D.,  Consulting 
Genito-Urinary  Surgeon  to  Mt.  Zion  Hospital,  San  Francisco. 
i2mo  of  405  pages.     Cloth,  ^2.25  net, 

Johns  Hopkins  Hospital  Bulletin 

"A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The 
treatment  of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and 
judicious." 


14  SAUNDERS'    BOOKS   ON 


Second 
Edition 


Wells'  Chemical  Patholos(y 

Chemical  Pathology.  Being  a  discussion  of  General  Path- 
ology from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.  D.,  M.  D.,  Assistam  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  6i6  pages. 
Cloth,  ^3.25  net. 

Wm.  H.  Welch,  M.  D.,  Professor  of  Pathology,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and 
I  shall  be  glad  to  recommend  it  to  my  students." 


The  New   (2dj   Edition 


Saxe*s  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
formerly  Instructor  in  Genito-Urinary  Surgery,  New  York  Post- 
graduate Medical  School  and  Hospital.  i2mo  of  448  pages,  fully 
illustrated.  Cloth,  ^1.75  net. 
Francb  Carter  Wood,  M.  D.,  Adjunct  Professor  of  Clinical  Pathology,  Columbia  Uni- 
versity. 

"  It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is, 
indeed,  better  than  a  good  many  of  the  larger  ones." 

deSchweinitz  and  Randall   on  the  Eye,  Ear» 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweimtz,  M.D.,  and  B.  Alex- 
ander Randall,  M.D.  Imperial  octavo.  125 1  pages,  with  766 
illustrations,  59  of  them  in  colors.  Cloth,  ;^7.00  net;  Half  Mo- 
rocco, $8.50  net. 

Griinwald  and  Grayson  on  the  Larynx 

Atlas  and  Epitome  of  Diseases    of  the  Larynx.     By  Dr.  L, 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  ^University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth, 
;^2.50  net.     /;/  Saunders   Hand-Atlas  Series. 

Mracek  and  Stelwagon's  Atlas  of  Skin         f^^ 

Atlas  and  Epitome  of  Diseases  of  the  5kin.  By  Prof.  Dr. 
Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry 
W.  Stelwagon,  M.D.,  Jefferson  Medical  College.  With  yy  col- 
ored plates,  50  half-tone  illustrations,  and  280  pages  of  text.  In 
Saunders'  Hand-Atlas  Series.     Cloth,  $4.00  net. 


EYE,    EAR,    NOSE,    AND    THROAT. 


deSchweinitz   and    Holloway  on  Pulsating    Exoph- 
thalmos 

_  Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre. 
viously  analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  $2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

British  Medical  Journal 

"The  book  deals  very  thoroughly  with  the  whole  subject  and  in  it  the  most  complete  account  ot 
the  disease  will  be  found." 

Jackson  on  the  Eye  The  New  (2d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  184  beautiful 
illustrations.     Cloth,  ^2.50  net. 

The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo'  is  an  appropriate  one  to 
apply  to  this  work." 

Grant  on   Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
of  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  ^2.50  net. 

Preiswerk  and  Warren's  Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Prof.  G.  Preiswerk,  of 
Basil.  Edited,  with  additions,  by  George  W.  Warren,  D.D.S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  With  44  lithographic  plates,  152  text-cuts,  and  343  pages 
of  text.      Cloth,  ^3.50  net.     In  Saunders'  Atlas  Series. 

Asher*s  Chemistry  and  Toxicology 

Chemistry  and  Toxicology  for  Nurses.  By  Philip  Asher,  Ph.G., 
M.  D.,  Dean  and  Professor  of  Chemistry,  New  Orleans  College  of  Phar- 
macy.     1 2 mo  of  190  pages.     Cloth,  1 1.25  net. 


1 6  SAUNDERS'  BOOKS  ON 

Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M.  D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New 
York.  1 2mo  volume  of  204  pages,  fully  illustrated.  Cloth,  ;^  1.25  net. 
British  MediceJ  Journal 

"  riie  methods  of  exLimining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book  some   extensive   tables  drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's    Essentials    of    Eye  Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  PolycHnic.  Post-octavo  of  261  pages,  82  illus- 
trations. Cloth,  $1.00  net.  In  Saunders'  Question-Compend  Series. 
Johns  Hopkins  Hospital  Bulletin 

"  riie  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason*s  Nose  and  Throat  Fourth  Edition.  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  112 
illustrations.  Cloth,  $1.00  net.  In  Saimders'  Question  Compends, 
The  Lancet.  London 

"  The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of  the  Ear  Third  Edition.  Revised 

Essentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.     Post-octavo  volume  of  214  pages,  with    114  illustra- 
tions.    Cloth,  $1.00  net.      In  Saujiders'  Qiiestion-Compend  Scries. 
Bristol  Medico-Chirurgical  Joumzd 

"We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  information." 

Wilcox  on  Genito- Urinary  and  Venereal  Diseases 

The   New   (2d)   Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases 
and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.  1 2mo 
of  321  pages,  illustrated.     Cloth,  $1.00  net.     Saunders'  Compends. 

Stevenson's  Photoscopy 

Photoscopy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Stev- 
enson, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
i2mo  of  126  pages,  illustrated.  Cloth,  ^1.25  net. 

Edward  Jackson.  M.  D..  University  of  Colorado. 

"It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emergent 
pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better  than  any 
previous  account." 


ct-n/s 


RC73 
Morrow 


M83 

1915 

Copy  1 


NOV  7 


